Dublin’s Rotunda Hospital has hit the headlines again in recent days. This time, it’s not because the hospital is bursting at the seams and failing to get planning permission for a badly needed critical care wing.Instead, it’s all about the startling revelation that consultants on the new public-only Sláintecare contracts are engaged in private practice with the blessing of the Master of the Rotunda, Prof Sean Daly, and the hospital’s board.A head-on collision seems inevitable as the HSE, the Department of Health and the Minister for Health Jennifer Carroll MacNeill line up to say this has to stop.Although you might be forgiven for assuming that consultant obstetricians would jump at the opportunity offered by Sláintecare to replace the discriminatory triple-tier public/semi-private/public system with a single-tier public system, it was never going to be easy to implement this level of radical change.One has only to read Sam Coulter-Smith’s Delivering the Future – Reflections of a Rotunda Master (Irish Academic Press, 2022) to realise how deeply ingrained the suspicion in the Rotunda is towards the HSE and the department. [ Rotunda told funding could be pulled over public-only consultants providing private care ]The department is seen as seeking to rob the Rotunda of what all voluntary hospitals prize most: its independent system of governance (embodied in all three Dublin maternity hospitals in the position of master who, first and foremost, reports to the hospital’s own board). To be fair, Coulter-Smith’s main broadside against the HSE (and its predecessors) and the department has some justification: namely the chronic underfunding of maternity services by the State.As Ireland’s busiest maternity hospital and a flag-waver for voluntary hospitals, what happens next in the Rotunda may not only determine its own future, but also that of other voluntary hospitals (including the other two Dublin maternity hospitals). How this controversy plays out may end up determining the future of a single-tier public hospital system.So, what is the problem and how can it be solved?Despite the falling birth rate, a decline in women seeking private maternity care, and the fact that every mother in the state delivers her baby in a public maternity hospital/unit (there are no private maternity hospitals), there remains a significant capacity problem. And if the private clinics traditionally run by consultants outside their contacted public hours suddenly become public clinics, the squeeze on maternity services intensifies. The same applies to obstetrical care traditionally provided in private practice hours to private patients in labour.Although delivery numbers are down, the rate of clinical complexity has increased due to women giving birth when they are older, more with medical conditions becoming pregnant and interventions at increasingly lower gestations. Simply put, there are not enough public consultant hours in the public system as it is.On top of this is the loss of income paid to public hospital by private healthcare insurance companies, which is used to fund the totality of the service.The issue that has the Rotunda and private consultants at loggerheads with the department could have been avoided by better planning on both sides of the table.Rather than trying to scupper the implementation of public-only care in public maternity hospitals or units by demanding a permanent exclusion – or dragging their feet in the hope the whole thing would implode – obstetricians should have rolled up their sleeves and played hardball with the HSE and department to put the necessary provisions in place to make the plan work.Equally, the Government and its agents should not have tried to railroad a poorly thought-out implementation plan through; they should also have listened more attentively to the concerns expressed by women and their obstetricians.A five-year transition to full implementation in the maternity services would have been far better than the three years given across the board to all hospitals.During this time, obstetricians who wished to practice privately in future might have explored the development of private maternity units – particularly in association with current private hospitals. However, given prohibitive medical insurance costs and the history of previous private maternity hospitals in the State (Mount Carmel closed in 2014), a successful delivery would have been unlikely.Women who chose private maternity care often cite the reason as the continuity of care it offers as well as the first-hand availability of a consultant in labour (rather than second-hand after the registrar). An expansion of midwifery-provided care can provide greater continuity; the days of the consultant being on-call for the labour ward from home need to be consigned to history. Surely, this is what all women deserve?As for the here and now, the Rotunda, the HSE and the department need to sort this out together. A binding agreement by the Rotunda to implement fully Sláintecare in return for a deadline extension of another two years, combined with the necessary resources, could serve as the template for a more successful implementation across all 19 public maternity units. This could also mean an increased uptake of the new contract by more obstetricians presently doing private practice under their old contracts. Meanwhile, consultants who have signed public-only contracts need to stick to the terms of their contract; additional clinical commitments need to be brought within the public system. The future of all voluntary hospitals also needs to be looked at; their glory days as powerful, autonomous Renaissance-like city-states may well be numbered. The new State-funded National Maternity Hospital needs also to be both a national and a public-only hospital. More than a century after the creation of the State, it is high time women had equity in relation to high-quality public maternity care – and that all babies are cherished equally when they are born.Chris Fitzpatrick is a retired consultant obstetrician and gynaecologist and a former master of the Coombe Hospital. He is currently a clinical professor at UCD