Final decisions on the National Paediatric Hospital will be made shortly. One key element in the plan is colocation. What is it, and what are the implications of colocation for hospital site selection?
Colocation is the location on the same or adjacent sites of a children’s hospital, an adult hospital and a maternity hospital. There are several distinct types of colocation, with different objectives. To begin with I consider the likely effects of different types of colocation on patient care.
First, is colocation of paediatric services. The aim is to put all national tertiary paediatric services, and the secondary paediatric services for the Dublin region, on one site. At the moment these services are split across four sites, Crumlin, by far the largest site, Temple St, Tallaght, and Beaumont. There are several reasons why this is a good idea.
- Managing the complex needs of very sick children demands close co-operation between many specialist doctors, nurses and other experts.
- Requiring some staff to work across sites, imposes heavy travel time costs on them, and reduces the level of service they can provide.
- There are significant economies of scale in providing access to costly technologies, for example MRI and PET scanners, the more complex laboratory facilities, and specialised theatre facilities.
- Facilities with high throughput of patients are better for training more specialized clinical staff, and provide more opportunities for research.
- Follow-up and rehabilitation care for recovering children often requires intermittent access to a wide range of specialists, which is easier to provide at a centre supporting a full range of services.
- Provision of education and play for sick children, some of whom will spend many months, or even several years, on and off, in hospital.
- Provision of both on-ward and off-ward accommodation for the parents of seriously ill children.
To achieve this any proposed site must have space for the full range of secondary and tertiary paediatric services. This is the case for most of the major international childrens’ hospitals.
Colocation of the children’s hospital and a major maternity hospital is also of great practical importance. The aim is to have immediate access to a full range of specialists, operating theatres and intensive care for the sickest newborn babies. This matters because, about one quarter of the children currently in the intensive care unit in Crumlin are newborn babies. Many of these high risk babies can now be identified before delivery. This allows the transfer of their mothers for delivery, which is much better for the baby than a long ride, late at night, in an ambulance. This colocation will support the future development of new specialised services, such as foetal surgery.
Colocation of an adult hospital and a maternity hospital has been less often discussed, but is also important. Every maternity hospital already has arrangements with local adult hospitals to support the care of pregnant women. Colocation makes these arrangements more substantial, and allows their wider development. A small number of pregnant women each year develop serious illnesses, beyond the capability of even a well-equipped maternity hospital. Equally, a small number of seriously ill women are also pregnant, and need the expert intervention of obstetricians and midwives to secure the best possible pregnancy outcomes. In both cases, this is best achieved by access to an onsite, or adjoining, adult hospital. The three big Dublin maternity hospitals are almost unique worldwide in not having such facilities.
Colocation of a childrens’ hospital and and adult hospital also has some clinical benefits. In the past, many of the more specialized paediatric services were provided by adult specialists who also did some paediatric work. This model of practice is passing, and almost all paediatric services are now provide by fully trained paediatric specialists. What is more relevant, is the transfer of care from paediatric services, to services for older adolescents and adults. This is facilitated by colocation, but only adolescents living in Dublin will benefit, as those living outside will have their care transferred to their local hospitals anyway.
Trilocation, that is the provision of maternity, paediatric, and acute adult hospital services on the same or adjacent sites is an ideal model. Most, but not all, of the large modern children’s hospitals that I have reviewed, are colocated with a maternity hospital, and a majority are colocated with an adult hospital. This model, if run well, provides the clinical benefits of the other types of colocation.
Besides the clinical benefits, better integration of management systems brings huge benefits. These include better efficiency, leading to lower costs, and better operational performance, leading to better outcomes. Many of these improvements do not require colocation, but all will be facilitated by it. These include common governance and audit systems, common infection control, common purchasing and personnel systems, common laboratory, imaging and IT facilities, more effective staff management, and better accountability for service delivery. Arguably, if colocation is to succeed, setting up this integration ought to precede the design and build of the new hospital buildings. Indeed, it would be fair to criticize the existing National Paediatric Hospital board, for their failure to begin doing this.
A further advantage of a single paediatric facility is in building up the scale and scope of both research, and training. The existing hospitals have modest, and moderately successful, research units. This division of a limited capacity across three sites seriously impedes Irish research into childhood disease. Horizon 2020, the next EU funding scheme for research has great opportunities for Ireland. Other countries have built major clinical and biological research centres, which are major employers. To do this, we would need a critical mass of researchers, doctors, nurses and patients. The NPH, on a single site, beside a research active adult hospital, would be a great start. Training is also inhibited by the the fragmented paediatric services. Ireland does not have the resources to provide advanced training in the care of sick children in three places. Again, a single hospital will greatly improve our capacity to offer advanced training to the next generation of doctors, nurses, and other child health professionals. Co-location with maternity and/or adult hospitals will provide further benefits in training and research.
Any proposed site for the new hospital needs to have the space to include all of these elements. A single acute inpatient facility for the children of Dublin, and a single tertiary centre for the children of Ireland, ought both to be non-negotiable. In my view, the next requirement is a colocated maternity hospital. Given the fiscal realities of Ireland today, this means one of the three Dublin maternity hospitals, based on its present site. It is nice to dream of shiny new maternity hospitals on green field sites, but its not going to happen. The very sickest babies in Ireland ought to be spared long ambulance transfers wherever possible. An acute adult hospital, either on site, or adjoining is also very desirable. Finally any site must have space for expansion. New buildings will be needed. Old buildings will need to be refurbished. Doing this essential work on a cramped site raises costs and increases the risks to children.
We can built a really good facility for Irish children, for Irish mothers and for Irish adolescents. We need less territoriality, less spin, and more focus on the actual needs of sick children and their families. We need the integration of management systems, and boards, to begin as soon as the constituent bits are identified. We need all of this in the next few weeks. Will we get it? Watch this space…