Peter Boylan: Big problems remain over new NMH structure

The announcement by the Sisters of Charity that they are to withdraw from ownership of the St Vincent's Hospital Group (SVHG) is to be welcomed. There has been an explicit statement that ethical guidelines based on canon law will cease to apply within the group. This removes the spectre of Catholic ethos influencing clinical care in the new National Maternity Hospital, which has been a cause of widespread public concern. While Catholic teaching has little influence on general medicine and surgery, the interface with obstetrics and gynaecology is fraught with difficulties. This is, therefore, a positive development in the plans for the new hospital.

Further clarity is now required on the new St Vincent’s company, but it is reassuring that it will be established under Irish company law, and not as a canon law structure such as a Public Juridic Person.

Significant problems remain, however, in respect of the ownership of the new hospital and its corporate and clinical governance.

The agreement between the two hospitals brokered by former head of the Workplace Relations Commission Kieran Mulvey has no legal standing in underpinning the proposed move, yet it appears that it is being interpreted by some as binding. In fact, no legal document has been produced giving substance to its terms.

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As of now no meeting of NMH governors has been convened to discuss the proposed move

I was assured in November 2016 at the NMH board meeting that endorsed the Mulvey report that no final decision on relocation to Elm Park would be made until the governors had been consulted and had voted on an appropriate legal agreement. However, some five months later the two hospitals had not even met with a view to developing the memorandum and articles of association necessary to give binding legal status to the arrangement between the two hospitals. As of now no meeting of NMH governors has been convened to discuss the proposed move. Yet in the press on Monday, James Menton, chairman of SVHG, represented the terms of the Mulvey report as a fait accompli. In contrast, the Minister for Health has stated that discussions will, and must, continue to tease out the issues of ownership of the new hospital.

Public assurances have been given that the NMH would have “complete independence” at Elm Park. There were assurances that a “triple-lock” would be in place guaranteeing independence, and talk of “reserved powers” and a ministerial “golden share”. Unfortunately, however, these assurances do not stand up to scrutiny. Critically, the NMH board is not included in the clinical governance structure proposed in the Mulvey report. The role of the NMH board would, in fact, be limited to campus governance, such as estates and facilities management. Bizarrely – and I suggest unacceptably – this means that the new NMH board would have no role in the clinical governance structure of the new maternity hospital.

The Mulvey factor

There is a statement in the Mulvey report that the role of master would be retained in the new hospital as per the policy of the National Maternity Strategy, Chapter 6: ‘Workforce and Governance’, which acknowledges that the model has served the country well over 260 years. What is proposed, however, is manifestly neither the Mastership as it has been successfully practised at the NMH since 1894, nor the model as described in the National Maternity Strategy, which states inter alia in section 6.7 that into the future (i) “Responsibility for corporate and clinical governance will rest with the Master (or Network Manager outside the Dublin maternity hospitals) and (ii) The Master will be accountable to the (Hospital Groups) Group CEO.”

Maternity services have too often been the Cinderella units of general hospitals with the result that funds have been prioritised away from them

In fact, future masters have been relegated to the fourth tier of the of St Vincent’s management structure, with a dual reporting arrangement to both the group medical board medical executive and the SVHG clinical director, who reports to the SVHG chief executive, who will report to the St Vincent’s board of directors. The master would no longer report to the NMH board, but would be a member of it. This is clearly not independent clinical governance under any definition.

It would be irresponsible to hand over governance of the national maternity hospital to a general hospital board that has no experience or competence in the provision of maternity services

In my decades of clinical experience, and especially in recent years with the reviews I have undertaken for the HSE, I have seen at first hand the dangers of integrating maternity units into general hospitals. Maternity services have too often been the Cinderella units of general hospitals with the result that funds have been prioritised away from them. Co-location is international best practice and the mastership model of leadership is a key pillar of the National Maternity Strategy. It would be irresponsible to hand over governance of the national maternity hospital to a general hospital board that has no experience or competence in the provision of maternity services.

Currently the NMH is held in trust by its governors, and this model has served women and their infants well over the past 120 years. In the future, only completely independent clinical and corporate governance structures should be accepted by the NMH to safeguard best clinical practice. A final decision should only be made when the Memorandum and Articles of Association have been drawn up, subjected to scrutiny, and found to be acceptable. In this respect, Mr Menton and the board of SVHG cannot continue to insist, Canute-like, that the Mulvey agreement stands.

There is clearly massive public support for a truly independent NMH. The decision of the Sisters of Charity opens a window of opportunity to achieve this.

• Dr Peter Boylan is a governor of the National Maternity Hospital, and chair of the Institute of Obstetricians and Gynaecologists