Four years after they last hit the streets, demonstrators will again gather in Dublin on Saturday to protest against Catholic influence of any kind in the National Maternity Hospital.
The project remains mired in controversy. Not a brick has been laid, while the projected cost has jumped from €150 million to €850 million. Now there is talk of moving away from St Vincent’s in Blackrock in Dublin 4.
This week, the debate has almost entirely centred on the control to be exerted by the nuns and the Catholic Church, or not, with the goal of what is best for the State's mothers and babies, and the role played by private medicine in that care, getting far less attention.
The Religious Sisters of Charity founded St Vincent's and are offering land there for the maternity hospital. While the nuns are bowing out, the land would be owned by a St Vincent's holding company, rather than the State, though the building would be owned by the State.
The site is surrounded by existing St Vincent’s Hospital buildings. Hence St Vincent’s says it must own the land in order to have integrated operations once the new hospital is built.
While any employer would prefer uniformity across its operations, the hospital’s argument is weakened by the diversity of arrangements in place in other parts of the health service.
St James’s Hospital, for example, operates on land leased from the HSE and exists alongside separate cancer operations, a HSE-run psychiatric centre and, soon, the new national children’s hospital.
Cork’s maternity hospital, an amalgamation of former public and private maternity units across the city, is, meanwhile, under the governance of Cork University Hospital.
If the estate agent’s mantra of “location, location, location” is really true, St Vincent’s ticks the boxes. Located in Dublin 4 , it is optimally placed to profit from the provision of private medicine.
In 2010, it opened Ireland’s largest private hospital cheek by jowl with the public building, allowing consultants to move seamlessly from one to the other, where allowed.
With the addition of a maternity hospital, St Vincent’s could effectively provide a “cradle to grave” service, though, equally, it is doubtful whether St Vincent’s ever wanted it, and it must now be rueing the decision to take it on.
In the welter of concerns over possible church influence, it is easy to forget the 2017 Mulvey deal on governance and operation was backed by the National Maternity Hospital, including former master Rhona Mahony, whose liberal credentials are not in doubt. Among the leading lights of the NMH, only Peter Boylan, another former master, opposed the deal.
Mahony and the NMH believe the Mulvey agreement guarantees independence from either St Vincent’s or the Catholic church, while also offering integrated public and private obstetric and gynaecological services.
The co-existence of public and private medicine in maternity was evident this week, when a couple settled their High Court case over the wrongful termination of their baby against the NMH, a public institution, and a private foetal health clinic operating next door. In Ireland, non-invasive prenatal testing and many fertility services are privately provided.
Under Mulvey, the NMH secured the continuation of the centuries-old mastership system, but how well does this practice of confining leadership to clinicians sit with 21st century management practice?
When other options for transferring the NMH from Holles Street fell through, the site in St Vincent's was seized upon as a solution by former Fine Gael minister for health James Reilly in 2013.
Holles Street, so old it was mentioned in James Joyce’s Ulysses, needs a more modern home, but this is true, too, of the two other Dublin maternity hospitals, the Rotunda and the Coombe.
However, the numbers of births in the State has been falling , relieving some of the undoubted pressures that these hospitals have had to face over recent years.
Reilly's decision, seen then as a payback for support by NMH doctors for abortion legislation, was hastily arrived at. It quickly unravelled. In 2016, then minister Simon Harris brought in industrial relations troubleshooter Kieran Mulvey to broker a deal between St Vincent's and the NMH.
That seemed to release the logjam. Yet this deal also foundered, in spite of its elaborate array of “golden shares” and “triple locks” aimed at ensuring operational independence. Under it, the State would lease the land for 99 years, not own it.
Around the negotiating table, “old Ireland” had hacked out a compromise that took account of existing structures and divided the spoils of power and control between the two institutions.
Maybe one-third of healthcare in Ireland is delivered by voluntary hospitals not under HSE control, including both St Vincent’s and the NMH, and nobody around the table imagined that was going to change.
And it hasn’t, with the State happy to fund services not under its direct control. Currently, for example, more than €100 million is being invested in a new block at the Mater hospital, which also has a Catholic ethos.
The counter-argument is that the maternity hospital arrangement is new. Rather than preserving the status quo, it could extend church influence, campaigners argue.
The virtues of State-owned medicine have been promoted in this debate without consideration of its performance. Not everyone agrees that voluntary hospitals are better run, but many do.
Patients will be well served by the co-location of adult and maternity services staffed by doctors in two of the State’s best hospitals, building on years of co-operation between specialists in both.
Meanwhile, it is HSE hospitals that are falling short on providing abortion. Just five of the 16 HSE-run hospitals offer a full termination of pregnancy service, compared to three out of three voluntary maternity hospitals.
Ethos barely featured in the Mulvey talks, but for “new Ireland” protesting on social media and on the streets, it has been the touchstone issue, since public opinion has moved on since the new NMH Mark II was first mooted.
Back then, abortion in Ireland was limited and same-sex marriages were illegal, while Tuam and the mother and baby home revelations had yet to see the light of day.
In the Dáil this week, TDs recited a litany of church scandals to condemn the St Vincent's plans. "Women were reduced to breeding beasts" during labour, Sinn Féin TD Reada Cronin declared.
Set against that, the assurances given by St Vincent's and the nuns that the new NMH would be clinically independent, with no religious or Vatican influence, have have cut no ice.
It says all medical procedures “in accordance with the laws of the land” are available in its hospitals, including pregnancy termination, tubal ligation and gender reassignment.
Over the year, it has proved difficult to fully test this assertion. Abortions have been carried out at St Vincent’s to save the lives of pregnant women, though tubal ligations or vasectomies were in the past referred elsewhere.
In 2005, oncologist Prof John Crown said a hospital ethics committee raised concerns about a cancer trial in which women would have to use contraception; the claim was denied by the hospital.
Since then, the nuns have ended direct involvement in St Vincent’s Hospital Group. They sought and received permission from the Vatican to transfer ownership to the holding company.
But the lay leaders of St Vincent’s, including former KPMG partner James Menton, the chairman of St Vincent’s Healthcare Group, have continued to insist on the need for a “safe, integrated system of care ”.
Four years have passed without a final agreement, before Tánaiste Leo Varadkar’s declaration of concern last week about the hospital not being built on State-owned land and over the number of State directors on its board.
What seemed acceptable, at least in principle, to the previous Government is not to the current three-party administration. Fine Gael denies that this has anything to do with the looming Dublin Bay South byelection, but others doubt that.
After that, the Government’s options are stark. Compulsory purchase could take years, so would a move to another site. The prospect of the nuns selling the site to the State seems distant, though not impossible.
Everything else includes clampdowns by the Government. Meanwhile, whatever route is used to progress the project, the costs that will be faced by the taxpayer will be horrendous.