IT WAS the news story that was supposed to go away. The Health Service Executive (HSE) had spoken, the deal was done: the Mater was to be the home of a new national children's hospital, a worldclass paediatric service that would finally drag Ireland into the 21st century.

The cracks of opposition may have appeared early, but the eruption occurred only at the start of this month, when Crumlin hospital spectacularly pulled out of talks. Since then, the public has been inundated with conflicting expert reports, rumblings of political intrigue, red herrings and general confusion.

Few things are more emotive than the thought of sick children, but what was once an idealistic argument has descended into open warfare. It's plain to see that a consensus will never be found - now it's about who will win.

Will the service be divided across two sites, in direct defiance of the McKinsey report which recommended the Mater site, or will yet another team of international experts be wheeled in to put us straight? Is the HSE capable of retaining the Mater site in the face of such conflict?

The Sunday Tribune goes back to the beginning and examines the facts of an issue that has gradually become distorted beyond recognition.

DO WE REALLY NEED A NEW CHILDREN'S HOSPITAL?

FOR years, two of the three major children's hospitals, Our Lady's Hospital, Crumlin, and Temple Street Children's Hospital have been calling for bigger and better facilities. The term 'falling apart' may not have been used directly but these hospitals have been a mess for years.

Other populations of our size tend to have tertiary paediatric care, which involves placing all top-class facilities for sick children under one roof. The McKinsey report, commissioned by the HSE to look into Ireland's need for a tertiary service, found that a minimum population of between three-and-a-half million and five million is necessary for such a hospital.

The report went on to look at the type of services that should be in such a hospital but, contrary to popular belief, location was not examined. The McKinsey report always assumed the hospital would be in Dublin, based on international best practice. It studied 17 other such hospitals around the world, all of which are in major cities.

Last week, a hopeful Irish Times reader wrote a letter asking why the new hospital can't be in Athlone, arguably the most central location in Ireland. It can't, and the reason is simple. Dublin has 34% of the country's children. Crucially, it treats 52% of the country's seriously ill children. Cases treated in hospitals outside the capital have been found to be of a less serious nature. The average hospital stay for a seriously ill child is 4.5 days outside Dublin, 19 days in the city.

Therefore, Dublin is where parents are already bringing their seriously ill children for services like chemotherapy, transplant surgery, cardiology and neurosurgery.

Dublin is where the services are and where the hundreds of specialists and medical staff required are based. Dublin is where it has to happen.

DID THE HSE PLAY GOD IN CHOOSING THE LOCATION?

FINE Gael has called for a new and more transparent report, for which a team of international experts would visit the country and give their verdict publicly on where the new children's hospital should be located.

"We have no idea how the HSE scored the various hospitals. They didn't give anything on how they reached the decision, " says Liam Twomey, Fine Gael spokesman on health. "We need a new report because, as long as there is a shadow of doubt over this process, there will be residual anger."

A new report is unnecessary, says Fionnuala Duffy of the HSE task force. "We had the McKinsey report which told us exactly what we need in terms of a new children's hospital and we were charged with finding the site, " she said. It chose the Mater Hospital site.

"This was not a tender and it wasn't a bidding process. We used our expertise to examine the sites and to choose the best location. People are saying there were no medical experts on the task force, but they seem to forget we had the Deputy Chief Medical Officer and the director of the National Hospitals Office looking at this issue."

The process of site elimination is outlined in the location report. Tallaght children's hospital and St Vincent's hospital were seen as not containing the necessary tertiary specialities, while Beaumont hospital was deemed to be too difficult to access. It soon came down to a choice between St James's and the Mater.

After detailed analysis of both locations, the Mater was chosen because of the type of services already available there and the speed with which it could be completed, amongst other factors.

However, Crumlin and Tallaght hospitals maintain that not enough sites were looked into. Crumlin has consistently called for a greenfield site to be developed, while Tallaght says the site at Newlands Cross, which developer Noel Smyth offered to the HSE, was never adequately considered.

WHAT'S SO GREAT ABOUT THE MATER?

SINCE the Mater was chosen, it has been getting it in the neck from all sides: it's not big enough; there is no car parking; and most importantly, its location in the city centre makes it inaccessible for the vast majority of Irish people.

Since Crumlin hospital kick-started the serious rows, every mother in Ireland has been phoning up live radio to discuss how it would take her half an hour to get to Tallaght, but two hours to get to the Mater.

In defence, HSE chief executive Brendan Drumm has said the Mater site will be twice as big as the existing three hospitals put together. Claims by Crumlin hospital that it will be impossible for the Mater to have control over a multi-storey underground car park have been rejected by the HSE. When it comes to the location of the new children's hospital, Drumm is unequivocal.

"To say that this site is not an excellent site from a transport point of view is uninformed, " he says, pointing out that all of the tertiary children's hospitals across the world are in city centres. "Now if someone could identify in their minds some magical site in Dublin that we could all get free access to and we could all drive there in 20 minutes in the morning or evening? But nobody has come forward to do that."

A metro line stop is planned for the Mater, which will accommodate visitors and staff, although most sick children will travel by car. Transport reports commissioned by the HSE and Tallaght hospital have vastly different ideas on how long it will take to get to the Mater by car, but the issue is largely irrelevant.

This is because, while the new children's hospital will be caring for seriously sick children, it will not be the only emergency department in the city. Two care centres are to be set up around Dublin to look after emergency cases. So if you live in Greystones and your child has an asthma attack, you will not be driving across the city to the Mater, as is the common misconception.

ARE TALLAGHT AND CRUMLIN SORE LOSERS?

CRUMLIN Hospital was never a contender for the new children's hospital site, and in fact told the HSE it would be happy to pack up and move, as long as a superior site was chosen. But the Mater is not a superior site, Crumlin contends.

"Not all options were considered, " says Dr Fin Breathnach, consultant paediatric oncologist at Crumlin hospital. "If you're going to pick an adult hospital to which you're going to attach a children's hospital, you would expect it to have specialities that would benefit children. The largest number of children that we transfer out of Crumlin are to Beaumont Hospital for neurosurgery. The Mater doesn't have that [neurosurgery]."

The Mater doesn't have liver transplant, cancer care or blood disorder services either, all of which are vital for sick children. Crumlin wants a fresh site developed. This would rule out co-location with an adult hospital, something the McKinsey report recommended. But, says Crumlin, it was only a recommendation and Irish adult hospital services are too fragmented to allow for such a merger.

Last week, Crumlin did some serious flip-flopping on the issue by indicating that it may now rebuild its own site and remain in Crumlin. Somewhat petulant perhaps, but an excellent move in what, for Crumlin, has been an extremely successful bid to cast doubt on the Mater site.

Meanwhile, Tallaght hospital, which was in the running for the new children's hospital, has now indicated that it too wants to stay put. Chairman Alan Gillis revealed the plan last week, which means having two children's hospitals - one in the Mater, the other in Tallaght.

"The decision to single out the Mater site was taken without the necessary consultation with all the parties involved, " he said. "It is far too cramped and would not be conducive to the development of a patient-friendly hospital."

WHY CAN'T WE HAVE TWO HOSPITALS?

THE proposal for having two hospitals has come not just from Tallaght hospital but also from Labour and Fine Gael, as a form of compromise on the issue.

Before the Mater hospital site was chosen, there was widespread unanimity on the McKinsey recommendation that all tertiary care services should be in one place. Since the HSE announced its decision, however, new theories have been put forward suggesting that the site should be divided between both sides of the Liffey.

The McKinsey report, carried out by a team of international (and objective) specialists, had just one clear view on the subject: this should not be attempted.

"Children don't fit neatly into one subspeciality, " the report said. "If you're going to treat a complex child, you need to have all the sub-specialists and the whole multidisciplinary team there to provide care."

One specialist was quoted in the report as saying, "You cannot have two paediatric tertiary care centres focusing on different niches. I challenge you to find me an example of where that works."

The fact that everyone agreed with this theory until the Mater site was chosen does not lend much credibility to the twocentre idea, and the HSE has certainly remained firm on the issue. But could compromise lead to a division of services, against international better judgement?

"It's absolute madness to suggest that this be divided between two sites, " said Drumm. "I believe that could be challenged under the UN convention on the rights of the child."

Liam Twomey disagrees. "While the McKinsey report may have said that one site is best international practice, you still have to take into account local factors, " he said. "And these factors quite possibly lend themselves to two sites. This has to be examined."

POLITICS OR PAEDIATRICS?

SINCE the HSE announced the Mater as the winner last June, there have been rumblings of political influence directed squarely at Bertie Ahern. After all, can it really be a coincidence that the new children's hospital will be located smack in the middle of the Taoiseach's constituency?

Last week, Fine Gael senator Brian Hayes produced a letter that Ahern wrote to the then health minister, Micheál Martin, which left the Taoiseach open to charges of interference.

"Given that the intention is to move PATemple Street on to the Mater campus and provide a state-of-the-art children's hospital for north Dublin, and indeed the country, any further downgrading or de-skilling of Temple Street would not be in anybody's interests, " he wrote at the time.

Fine Gael says this letter goes some way towards proving political interference by Ahern, but the HSE maintains that the new children's hospital was the brainchild of Brendan Drumm and the plan came to fruition only on his appointment in 2005.

"We were always going to be open to these kinds of claims, " said a spokesman. "If the children's hospital had gone to Tallaght it would have been because of Mary Harney. If it went to Crumlin it would have been because Drumm used to work there. If we went to James's, people would have said it was because of John O'Brien, the director of the National Hospitals Office. Wherever you go, people will always raise these issues."

"I have no doubt there was political motivation behind this, no matter how much the HSE might deny it, " said Liz McManus, Labour health spokeswoman. "The most significant children's hospitals are digging in their heels for a reason. This is the biggest development in paediatrics in a long time and they have not pulled out of talks lightly.

We need to listen to them and we need an independent review."

DOES IT ALL COME DOWN TO TURF WARFARE?

TEMPLE Street Hospital is, of course, siding with the HSE decision to move it next door to the Mater. However, Dr Michael O'Keeffe of Temple Street gave a new insight into the row when he indicated that, if he had been asked to move across the city, he would have objected.

"What's going on is turf warfare, " he said.

"There is intense competition between the two sides of the city. That's well-known. I've seen it for years."

The idea that consultants wanting to stick to their own patch is at the heart of the issue is somewhat disturbing, but Tallaght's stubborn campaign to make its site the new children's hospital, not to mention the indication that Crumlin is going to start redecorating, calls into question exactly what forces are at work.

Some of the criticism of the Mater site has also been baffling, given that the building has yet to be designed. When Alan Gillis says it won't be patient-friendly, and when Dr Fin Breathnach says children need light, open air and green space, how do they know it won't be provided?

According to Brian Gilroy, estates manager of the HSE, critics cannot say the Mater hospital site will be too small, given that its floor space is double that of the three children's hospitals. They will certainly be providing play areas for children, he said.

The hospital will probably include highrise building, which Breathnach says is unacceptable. "Nobody has done that in the world, " he said. "No one has accepted highrise as being appropriate for the needs of children."

Gilroy countered that if you ask doctors at St James's Hospital, a sprawling campus, "they'd say it's better to go up rather than out." He added: "We can't go back to the old days of spending 12 years arguing, because we won't have a hospital that children need."

WHAT ABOUT THE CHILDREN?

ABSOLUTELY everyone agrees we should think of the children. What a pity then, that everyone thinks we should think of the children for entirely different reasons.

The HSE, the government and Temple Street hospital say we should think of the children, stop this dilly-dallying and get on with building a new children's hospital on the Mater site.

Crumlin hospital, Tallaght hospital and the opposition say we should think of the children and not wreck their lives by providing them with inadequate services.

But the parents' groups' message is much clearer: think of the children and start building a hospital. Now.

"Someone has to say stop, or this could go on forever, " said David Fitzgerald of the New Crumlin Hospital Group. "We just want a hospital. It doesn't matter where it is.

That's neither here nor there. If a parent has a seriously sick child, they will get them to the hospital where they can get the best care, regardless of where it is."

The New Crumlin Hospital Group was formed five years ago this week with one agenda: to get the children of Ireland a world-class hospital. Now that the dream is being realised, the group is dismayed that it has become a war of words.

"Our view is that we have waited long enough, " said Fitzgerald. "We don't know whether the square footage of the new site is enough or whether M50 traffic flow is a serious factor. That's not our role. Our role is to get this project moving, because the only people suffering here are the children. That is a fact that no consultants or politicians can get around. The parents of Ireland are just piggy in the middle while this debate rages and I think everyone is sick of it. Can we not just get this show on the road?"