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'Nun' of your business #MakeNHMOurs' Blog #2

Dr Camilla Fitzsimons (Maynooth University)

Ireland’s maternity services are in terrible shape, we can all agree on that. My own three stays in hospital (two in Holles Street and one in the Rotunda) were all on nightingale wards and the staff were clearly under pressure.

HIQA (Health Information and Quality Authority) agree. Their first inspections, carried out in 2018-2019 and benchmarked against their National Standards for Better Maternity Care, found gross noncompliance in two settings and varying degrees of noncompliance in others. They also found inadequate staffing in more than three-quarters of hospitals and often outdated physical infrastructure that fell short of international standards. Just 11 percent of promised public funding had been used leading HIQA to recommend an urgent acceleration of investment. You can read their full report here.

However, we simply can’t allow this diabolical situation to sleepwalk us into a deal that we could struggle to extricate ourselves from in the future. We have to get this right and the alarm bells that are ringing can’t be ignored. Here’s my four reasons why I think #DonnellysDeal has to be abandoned straight away before more time is lost. First some context.

The current debacle began nearly a decade ago when the decision was made to relocate the National Maternity Hospital (NMH) and involves a dispute about governance between the NMH and St Vincent’s Healthcare Group. Kieran Mulvey, former chair of the Workplace Relations Commission mediated between the two and helped thrash out an agreement where sole ownership of the new NMH would reside with St Vincent’s Healthcare Group (SVHG). One of the most surprising things about all of this is that Simon Harris, Minister for Health at the time, somehow convinced himself that people wouldn’t bat an eyelid about the fact that the majority shareholders of SVHG were the Sisters of Charity; one of four religious orders who incarcerated thousands of women in Magdelene Laundries throughout the 1900s. Although the government have apologised to survivors and have initiated a redress scheme, none of the religious orders involved have contributed to this.

A number of parallel protests immediately began. Denise Kiernan set up an online petition which gathered over 100,000 signatures and there were street demonstrations mostly organised under the umbrella of the ‘Campaign Against Church Ownership of Women's Healthcare’. The campaign involved the groups Parents for Choice, Midwives for Choice, The National Women’s Council, and others, all of who were actively pursuing repeal of the eighth amendment at the time.

There were also objections at NMH board level which culminated in the resignation of former Master Dr Peter Boylan. From the offset he has been consistently critical of this deal and I for one am grateful of his stance. Boylan wasn’t the only person to object to the deal rather councillors Mícheál MacDonncha of Sinn Fein, and then Lord Mayor of Dublin Brendan Carr of the Labour Party, also dissented. Carr relayed his principle reason as "€300 million of taxpayers money being spent on something the taxpayer won’t own” and reported a hostile and bullying attitude towards dissenters from others. There were other opposers too including Dr Chris Fitzpatrick, former clinical lead (Master) at the Rotunda, who resigned from the HSE board managing the project in support of Boylan's views.

In May 2017, the Sisters of Charity succumbed to pressure and announced they would end their involvement in St Vincent’s Healthcare Group. However, under canon law, selling (or gifting) the land needed the approval of the Archbishop in the first instance and then express permission from the Vatican. It took three years for this to be forthcoming then, in May 2020, the religious order confirmed it had been granted permission by the Holy See to transfer ownership of the land, something RTÉ reported at the time as a gift to the state. What was actually announced was the creation of a new company called St Vincent’s Holdings and it is the details of this company that warrants scrutiny. Its main objective, as laid bare in its Memorandum of Association is not as a landlord as some politicians appear to be implying but,

“to advance healthcare in Ireland - a purpose of benefit to the community, by promoting medical education, medical research and all patient care in all areas of medicine through the St. Vincent’s Healthcare Group and to reflect compliance with national and international best practice guidelines on medical ethics and the laws of Ireland through the provision of support to companies which are registered charities … and which are the Company’s subsidiaries”.

Amongst its subsidiary objectives, is a commitment to the same Mary Aikenhead led core values that guide St Vincent’s Healthcare Group namely 'human dignity, compassion, justice, quality and advocacy' (more about these values later).

The memorandum of association outlines a board structure of 3-10 people and three directors have now been appointed. They are Michael Keane, a respiratory consultant at St Vincent’s private hospital, David Brophy, vascular and interventional radiologist at St Vincent’s Hospital, and Sharen McCabe, director of McCabes Pharmacy. All three are former directors of St Vincent’s Healthcare Group.

On foot of pressure from the public and political opposition, the government has now also published the Memorandum of Association of The National Maternity Hospital at Elm Park one of four subsidiary company’s of St Vincent’s Holdings. The memorandum for this new NMH uses the term “without religious ethos” five times. St Vincent’s Holding Group, who the NMH will hold an operating license with, is named 34 times. This document outlines the 'golden shareholding' you might have heard about where St Vincent’s Holding Group will hold 99 shares, and the Minister for Health will hold 1 golden share. There will be nine directors, appointed as follows:

"(i) three (3) directors nominated by the Chartered Corporation (one of whom shall be the Master) and two of whom shall, in addition to being Directors, be appointed by SVHG to its board;
(ii) three (3) directors nominated by SVHG; and
(iii) three (3) independent directors nominated by the Minister in accordance with the applicable processes from time to time operated by the Public Appointments Service or any other body to which the applicable functions of the Public Appointments Service may be transferred (the 'Independent Director(s)')"

Section 14.7 of the same document also states that:

“The board of directors of SVHG and the executive committee of the Chartered Corporation have confirmed that any clinically appropriate maternity, gynaecological, obstetric, neonatal or related service which is lawfully permissible in the State shall be available in the new maternity hospital facility at Elm Park.”

Although things might on the surface seem in order, here’s my four reasons why I think this is a bad deal.

1. Why so complicated?

The first and most obvious problem is why is such a complex framework of agreements required? I'm not a legal expert but I am an academic and I certainly found it hard to get my head around the myriad of documentation that is available. Ivana Bacik, leader of the Labour Party and a legal expert in reproductive healthcare described the arrangements as “byzantine” which means excessively complicated and over-burdened with administration. She’s not the only legal expert to raise a red flag. TD and Barrister Catherine Connolly had said she is "deeply troubled" by the governance arrangements being proposed. Moreover, Professor of law at UCC Deirdre Madden and a board member of the HSE (along with Dr Sarah McLoughlin, patient advocate) both dissented to the board's approval stating they “continued to have concerns regarding legal ownership of the site and building, and the governance and control”.

Unanswered questions for some relate to conditions the Vatican may have attached to the deal, after all, why did they not just allow the land to be gifted to the state? If they did, why have the Sisters of Charity chosen not to do this? Here is a short video clip where Dr Peter Boylan summarises his concerns in this regard. Dr Chris Fitzpatrick (formerly of the Rotunda) also remains sceptical as evidenced through his own recent letter to the press.

I for one do not trust the motivations of the Catholic Church. In a recent Prime Time debate, the journalist Alison O'Connor claimed Ireland was suffering a hangover from the past and needed to move on. But this ignores the fact that the Catholic Church continues to be the biggest, most organised and most powerful anti-choice lobby group in the world. This is despite the fact that according to this fact sheet from Catholics for Choice, 75 percent of Catholics are okay with abortion in all circumstances and just 14 percent agree with the church hierarchy on this issue. Catholics for Choice are amongst the many voices who have accused the Catholic Church of strategically taking control of much healthcare in the US so they can incrementally erode reproductive rights. Why do they hate women so much?

If more evidence were needed, have a look at this article in the Irish Catholic about the NHM situation that explains how:

the Vatican has been urged to step in to block the transfer of land from a religious order to the State because abortions will be carried out in the new hospital”.

2. Why not a rights-based ethos?

There may not be nuns on the board, crosses on the walls or statues in the corridors, but claims that St Vincent's Healthcare Group does not hold a religious ethos are bogus. Even when announcing their decision to step aside, the Sisters of Charity guaranteed SVHG would continue to “foster Mary Aikenhead’s core values of human dignity, compassion, justice, quality and advocacy". If you can, hold it in your head that these very same principles are repeated verbatim in the MOA of St Vincent’s Holdings. This is an important point.

I can see that, on the surface. these values seem pretty standard. After all, who wouldn’t want these values at the heart of any care they receive. The trouble is terms such as ‘human dignity’ and ‘advocacy’ are highly subjective and are contested concepts. Take the value of human dignity described in Aikenhead's belief system as “the value of human life and the dignity and uniqueness of each person”. Or a second example where advocacy is described as speaking “for the voiceless, acting with and for them to achieve the right quality of care”. How a person interprets these sentences differs hugely depending on their own core values. In particular, most people who are anti-abortion believe human life begins at the point of conception. Speaking for the voiceless equally might be applied to a personified foetus. These are the values that dictate why, today, St Vincent’s Healthcare does not offer a full suite of reproductive health services - including tubal ligation, abortion on demand and vasectomies, despite this latter contraceptive option being the safest option for people who can get pregnant. This article in the Irish Medical Journal links this absence of vasectomies to religious ethos. Their current refusal of this and other services also breaches the WHO Framework for ensuring human rights in the provision of contraceptive information and services. St Vincent’s continue to insist they will offer all services as outlined in this statement on the issue from 2021. But there is a difference between something being available and something being actively normalised as part of reproductive healthcare.

There is an alternative namely a more internationally widespread rights based approach - the approach that underpins Sláintecare. HIQA have produced guidance on a Human Rights Based Approach to healthcare setting out five principles namely ‘fairness, respect, equality, dignity and autonomy’. This last right – autonomy is particularly important and is describes as:

“the ability of a person to direct how they live on a day-to-day basis according to personal values, beliefs and preferences, in a health and social care setting, autonomy involves the person using a service making informed decisions about their care, support or treatment”.

As you can see, it is each person’s own values that direct their care and not the values of the healthcare provider.

It is the absence of a clearly articulated rights based approach, made worse by the lack of an unambiguous list of treatments and services that will be offered from the outset, that understandably leads to suspicions about the terms “clinically appropriate” and “legally permissible healthcare services” that are scattered throughout legal documents. If a list were to be included, this would not need to be finite rather could be added to as dictated by evidence-based medical research.

3. Things must be airtight for the future.

Personally, I believe Stephen Donnelly is speaking sincerely when he implores us to believe that all services will be provided and that clinical independence will prevail; a claim he repeats a number of times in this short interview on Irish radio. But what about the future when Donnelly is no longer the Minister? There is a lot of room to maneuverer within his 'byzantine' proposals. A future Dáil minister might have a very different attitude to reproductive rights and, if we go with this deal, would have significant scope to be led by this ideology.

This isn’t just speculation plucked from the sky. We only have to look to Northern Ireland to see how the anti-abortion beliefs of Health Minister Robin Swann have clearly impacted the failure of his department to commission services. The US is another example. Fifty years ago, very few would have imagined the political landscape we face today where a raft of transphobic laws have been passed and where Roe v Wade will likely fall. None of this happened overnight it is the culmination of a politically instigated right-wing anti-abortion crusade that involved the phased introduction of TRAP laws where sometimes seemingly innocuous regulations chip away at abortion rights.

As it stands we are starting from a particularly low base. Nine publicly funded maternity hospitals in Ireland don’t offer full abortion services and have not been sanctioned for this. There is no doubt but that anti-abortions crusaders can influence such situations. Take Kilkenny as a case in point where four consultant obstetricians sent a letter to local GPs stating the hospital was unsuitable for abortions. One of these consultants, Trevor Hayes, was a prominent anti-abortion campaigner who actively opposed repealing the eighth amendment. One reason such behaviours are tolerated is because our law permits conscientious objection (I prefer conscientious obstruction) where a healthcare professional can refuse to provide care on the grounds of moral or religious beliefs. Although the WHO have in the past acknowledged the right to conscientious objection, their most recent Abortion Care Guidelines (2022) recognises that in many cases it “operates as a barrier to access to safe and timely abortion”. The WHO expressly asks governments to intervene where CO is hindering access to abortion care (p. 60) and suggest legal guarantees to ensure employment practices limit the numbers of conscientious objectors that can be taken on.

4. Because a new NHM should be state owned and on state land.

Even if we set aside these very real concerns about how a religious ethos might dictate services today or creep in incrementally, why on earth should we hand over a hospital that will cost over €1billion to build to a private company? One argument put forward to justify this madness is that there are other examples of a voluntary hospital model. But this doesn't make it right rather it is a legacy from catholic Ireland that should be actively abandoned at every turn.

We are also told that the a co-location model can only work when there is one over-arching ownership. This doesn't stack up given that it is not the model being applied in the re-location of Temple Street to the grounds of St James hospital.

What about the fact that, although the new NHM will be non-profit and a registered charity, another subsidiary company of St Vincent’s Holdings namely St Vincent’s Private, solely exists so it can squeeze profits out of health services. In this blog on the creeping privatisation of healthcare Rachel Tansey outlines the ideological tensions this can cause. She writes,

“greater health inequality is fostered as private, for-profit providers ‘cherry-pick’ lower-risk and paying patients, whilst higher-risk and poorer patients, or those needing emergency care, remain reliant on under-resourced (thanks to austerity) public health service provision”.

How will these differing ideologies co-exist where there is a shortage of theatre space for example? I don’t mean in an emergency situation rather in the long term allocation of space.

There are other questions too that I will lean on others to introduce. The Social Democrats ask about "the role of Stembridge Ltd and Porema Ltd – companies associated with tens of thousands of offshore companies – in establishing SVH?". Solicitor Simon McGarr raises a number of issues about missing documents, and a rent agreement where the €10 a month deal repeatedly touted as 'as good as state ownership' is not what is defined in the lease rather is conditional on the new NHM adhering to certain conditions set out by St Vincent's Holdings including a condition surrounding ‘clinical appropriateness’. If these conditions are not met - €10 automatically becomes €850,000. And this is on top of regular rent reviews that are build into plans.

Addressing these four concerns is simple: a secular hospital that is guided by a rights based approach and built on state owned land. If SVHG won't gift their land to us, then a compulsory purchase order should be pursued. Perhaps there will be no objections and the sisters will pay some reparations for the past. Otherwise we must move to another site for example Tallaght or Blanchardstown, both of which are easier to access for people outside of Dublin.

If I were to give birth again, I would gladly go back to Holles Street rather than agree to what I see before me. I urge everyone to get involved with the Make Our Maternity Hospital Ours Campaign who are doing amazing work. They have produced templates for writing to TDs and have organised a series of demonstrations including a well attended protest on the 14th May outside Dáil Éireann.

About me: I am a full time lecturer at Maynooth University. I hold a PhD in Adult and Community Education and I have a special interest in education within community spaces and social movements. In a previous life I was a general nurse and worked across a range of Dublin hospitals (including St Vincent's!) I am the author of the award winning book Repealed, Ireland's Unfinished Fight for Reproductive Rights which you can find out more about here.

Huge thanks to Sarah Murphy (formally of Make our Maternity Hospital Ours). I interviewed her a couple of months back and learned a lot regarding the issues at stake. Sarah also read through this before publication and picked up on mistakes I was making. If you see other faults in my case or have more to add, make sure to leave a comment below.

If you are in Ireland and need an abortion, follow this link.

The picture I have used comes from the Facebook page of the Make Our Maternity hospital Ours Campaign

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