Your guide to co-operation in Health Services

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The island of Ireland has a total population of just over 6.5 million people separated by an internal border stretching over 470 km.  It is well documented that the creation of the border in 1922 divided the island into two insular and centralised states whose institutions and political culture developed back-to-back ¹.  For many years, the two Health Departments on the island would not have considered each other’s perspectives in the course of their daily work, planning or service provision – although a mere 160 km apart.

Comparing the two health systems we can see significant differences in health policy, structures, coverage and funding.  Each system is led by separate structures and legislation and shaped by different experience and drivers.  The Republic of Ireland provides a mix of public and private health care with patients having to pay for some treatments provided free north of the border.  For example, there are charges for GP appointments although around a third of the population are entitled to free health care (income-related or aged over 70 years).  Approximately half of the population in the South are privately insured.  By contrast, Northern Ireland operates a NHS universal public healthcare coverage system with just over 10% of the population having private health insurance.  There are many other differences including the Southern policy of co-locating private and public hospitals, the different funding arrangements, the integration of social service and health in Northern Ireland, the much larger percentage of nursing staff in the South etc…

There are many common aspects to health in both jurisdictions.  Both North and South the health sector commands the largest allocation of public sector funding (current annual budgets €16.2b in the South and £3.7b in the North) and is the single largest employer (105,000 employees in the South and 40,000 in the North).  Both jurisdictions are facing health (and budget) challenges such as ageing populations, growing prevalence of chronic illnesses, and intensive use of expensive yet vital health technologies. Moreover, each system must deal with higher expectations of citizens and resolve persistent inequities in access and in health conditions among different groups.  Statistics² point to the important health challenges on the island including: high levels of chronic disease; increasing levels of sexually transmitted diseases;  nearly 40% of children take less than the recommended level of exercise; and about 25% of adults have literacy problems.  The island of Ireland has one of the most unequal societies in Western Europe.  Travellers lose 15 years of life compared with the settled population. Over half the adult population are overweight or obese and a third of children live in poverty.

CONTEXT

Co-operation in health is long established and has developed and strengthened over the years.  Since 2000 the Centre has been involved in evaluating the practical co-operation between health service providers in the immediate border region ³, reviewing the potential for upgrading all-island health services ⁴, examining the benefits of EU membership ⁵ and evaluating the development and implementation of a new cross-border service ⁶.  Throughout this work the Centre has documented enduring enthusiasm at political, service provider and community levels to developing future health co-operation.

The current context for North-South co-operation on the island of Ireland, in this as in other areas, is grounded in a series of international and inter-governmental agreements. The last of these agreements, the 1998 Good Friday Agreement, saw a new devolved power structure put in place in Northern Ireland and embodied a formal commitment to work towards specific objectives in relation to cross-border co-operation in health. Common health policies and approaches are agreed within the framework of the North/South Ministerial Council (NSMC) but implemented separately in each jurisdiction. Five specific areas for co-operation in health were identified: accident and emergency planning, major emergency planning, procurement of high technology equipment, cancer research and health promotion.  Although the devolved arrangements in Northern Ireland have been subjected to a series of interruptions, the Irish and British governments, and the EU, continued to give considerable encouragement to practical cross-border initiatives in health.  In May 2008 progress on North-South co-operation in health was reviewed at the seventh NSMC meeting in the Health and Food Safety sectoral formats.

Predating the intergovernmental co-operation agreements has been Co-operation and Working Together (CAWT)⁷, a partnership of the health boards, health trusts and Health Service Executive (HSE) in the border region.  CAWT has led the development of cross-border health work since the early 1990’s establishing extensive cross-border networks and implementing 78 EU-funded pilot projects in areas such as cognitive therapy, suicide behaviour, sex offenders, fostering care, health impact assessment training, and emergency planning (See Table 1).

Table 1. Recent health co-operation projects led by Co-operation and Working Together (CAWT)

Furthermore a strong evidence base for co-operation is being developed with recent all-island surveys and information systems developed on children’s physical and oral health, drug prevalence and use, diabetes prevalence, health inequalities, renal dialysis and road safety statistics.  The Institute of Public Health in Ireland, an all-island body established in 1998, is leading the way on strengthening public health intelligence, capacity and policy evaluation.  In August 2008 the Institute in partnership with the Derry Well Women launched the first ever cross-border plan ⁸ to tackle social deprivation in the border counties, focusing particularly on the north-west.  This ‘Levelling Up’ action plan was developed with 60 organisations from both sides of the border.  In August 2008 the Institute also launched a joint report ⁹ with the Combat Poverty Agency quantifying the contribution of social factors, such as poor housing, nutrition and education, to the higher level of ill-health found among poor and socially excluded groups in Ireland, North and South.

In setting out a compelling vision of a strong competitive and socially inclusive island economy, a recent British-Irish policy report ¹⁰ recommends exploring opportunities for planning and delivering all-island health services.  This seminal report comments on the more efficient use of new facilities, better value for money, more balanced regional development and improved access to services and facilities throughout the island that such co-operation could bring.  This clarity was particularly welcomed at a time when new EU operational funding programmes ¹¹ are being drafted.  Following this report the Irish National Development Plan called for a joint governmental study of the potential for cross-border co-operation.

THE CROSS-BORDER PICTURE

Border Ireland, an online searchable database of cross-border information available freely at www.borderireland.info, has grouped the over 3700 activities it holds into eleven sectors and 65 subsectors.  Health accounts for 8% of cross-border activity (Graph 1) and is classified into 12 different sub-sectors (Graph 2). (One caveat to these figures is that they represent the numbers of activities rather than depth of activity.)

Graph 1.  Border Ireland areas of co-operation (1982-2006)

Graph 2. Border Ireland sub-sectors of cross-border health co-operation

Border Ireland, working in partnership with the International Centre for Local and Regional Development, also allows us to looks at where this co-operation actually takes place.  This is done by aggregating the numbers of cross-border activities which happen within each county.  Looking specifically at the health activities during the period 1982 to 2006 (see map below) cross-border activity in health is shown to be most intense in the North West region in counties such as Donegal, Leitrim and Sligo in the South and Londonderry/Derry, Tyrone and Fermanagh in the North.  This activity is seen to  spread across the whole of the island and involves every county on the island.  In fact the Border Ireland website has registered 275 cross-border health activities involving 112 organisations on the island, with a 50% growth in such health activities since 2000.

Map 1. Spatial pattern of cross-border health activities (1982-2006)

CROSSING THE BORDER FOR HEALTH CARE

This briefing paper focuses on one aspect of health that of health services whilst recognising the important and growing focus on co-operating to maintain and promote health.

Data on the cross-border movement of patients between 1996 and 2003 provided by the two Departments of Health, North and South, and the Economic and Social Research Institute in the South approximately 16,000 patients have formally crossed the border to receive health care in the other jurisdiction. As expected most of the ‘cross-border’ patients were treated in hospitals in the former Eastern Health Board area (which includes Dublin), or those close to the border (formerly the North Eastern and North Western Boards) in the South, and Altnagelvin (Derry), Daisy Hill (Newry) and Erne (Enniskillen) in the North.

One of the most useful examples of health cooperation has involved contracting (by the health boards in the North and the National Treatment Purchase Fund (NTPF) in the South) for elective surgery to reduce waiting lists within each jurisdiction.  The establishment of the Irish National Treatment Purchase Fund in 2002 enables the health services in the Republic of Ireland to arrange and purchase treatment for qualifying patients in hospitals in Northern Ireland and further afield. Examples of treatments covered under the NTPF are cataracts, varicose veins, hernias, gall bladders, prostate, tonsils, plastic surgery, cardiac surgery, hip and knee operations. About 1000 patients, mostly from Donegal but some from Dublin and elsewhere in the South, have been treated in a private hospital near Derry in the North and approximately 600 patients have travelled to England.

Short Duration

In Northern Ireland such initiatives are invariably of short duration because of concerns on the part of the Boards that they should be investing resources to maintain the services in their own jurisdiction rather than exporting them.  An early example (1980s) is that of the arrangement between the Royal Group of Hospitals in Belfast and the Southern Health Board (now an area of the Health Service Executive) in the Republic of Ireland (covering the area around Cork) to provide hip replacements in order to reduce the waiting lists. There are still intermittent initiatives in which health boards in Northern Ireland contract with hospitals in the South, usually employing one-off funds made available by the Department to reduce waiting lists. Another example is the provision of ophthalmic services to patients from the old North Eastern Board (now HSE Dublin North East) in the Republic by the Mater Hospital in Belfast.

Within the border region there has been a number of temporary contracting arrangements developed under the auspices of CAWT.  These include a neonatal intensive care service provided under contract from Altnagelvin (North) to premature or sick babies from Letterkenny (South); patients who had been waiting for hernia surgery for more than 18 months at Craigavon Area Hospital (North) being treated at Monaghan General Hospital (South), and haemodialysis provided in Daisy Hill, Newry (North) to a small number of people from the Dundalk area (South).  Between April 2006 – March 2007 CAWT have facilitated a 12-month pilot Ear, Nose and Throat(ENT) service involving consultants travelling across the border to deliver extra patient out-appointments.  This has resulted in over 2880 patients being removed from the combined waiting lists of Letterkenny and Altnagelvin hospitals.

Sustained co-operation

There are also examples of sustainable co-operation.  For instance services providers on both sides of the Donegal/ Derry border are combining their respective populations to provide the critical mass necessary to maintain a joint oral maxillofacial service in the region.  The service is provided by a team of 4 consultants – 2 of whom are employed in Letterkenny (South) and 2 of whom are employed in Altnagelvin (North).  CAWT supported this initiative by providing initial funding for equipment.  Arrangements are also in place so that ambulances now take casualties of road traffic accidents (RTAs) and emergency obstetrics to the nearest hospitals irrespective of which side of the border the emergency occurs.  This follows work by CAWT on mutual recognition of registration and indemnity of health service professionals.  CAWT also co-ordinated two  major planning exercises involving over 400 people from 15 different organisations testing the practical implementation of joint training when responding to emergencies.

The two Departments of Health, drawing on CAWT’s expertise, have established a cross-border arrangement which enables up to fifty Donegal patients to have their radiotherapy treatment in Belfast as an alternative to travelling to Dublin or Galway.  The Southern Department pays for the increased unit capacity in the Northern hospital and for its patients to access it. It is expected that the new Regional Cancer Care Centre at Altnagelvin due to be in place by 2015 will facilitate long-term arrangements for Southern patients.  This is an impressive list of co-operative work led by health professionals working on both sides of the border.

Moving beyond EU funding

Moving from the traditional EU funding programmes to newer strategic measures we see health co-operation beginning to evolve beyond EU funding and to extend beyond the border region where it was innovated.   One example is the Good Morning telephone and alert serve community-based initiative dealing with social inclusion issues. It is a free telephone alert/information service for the elderly and people who feel vulnerable.  The concept originated in Glasgow in 2002, was first replicated in 2004 in Derry as ‘Good Morning North West’.  Two years later under the CAWT umbrella it was introduced across the border in the North Donegal Inishowen peninsula where it is managed by local volunteers many of whom are retired.  The concept has expanded in the South.  The HSE committed to fund the Inishowen service beyond the pilot phase. In June 2008 the Southern Minister of State at Health and Children with responsibility for Older People, Maire Hoctor, officially launched the North West Inner City “Friendly Call Service” project in Dublin, a similar spin-off project.  Ironically, while the service is growing on the Southern side of the border it is contracting on the Northern side with the Department of Social Development funding due to cease from 31 August 2008.

Other worthy projects which are seeking to expand include the computerised cross-border renal network, the NI Centre for Conflict Transformation accredited training of cognitive therapists, the Safefood local authority training in food allergen control and the highly significant GP Out-Of-Hours project where over 450 people living in parts of Donegal and South Armagh have chosen to use closer cross-border services than the existing services in their own jurisdictions.   Since January 2007 CAWT has overcome professional, legislative, technical, pharmacy, financial, secondary services and social care differences to enable a cross-border GP Out-Of-Hours service to be established – a huge achievement.  This bi-directional pilot has provided an excellent opportunity to look at the development and uptake of cross-border services.

MOBILE POPULATION

Among the main achievements over the past 20 years include proving that crossing the border for health care and delivering health care across the border is workable, practical and acceptable to people living on both sides of the border.  Despite this the level of cross-border services delivery remains very low. In 2004 research under the Europe for Patients project ¹² showed that the official numbers of patients and professionals crossing the border to receive or deliver health care in the other jurisdiction has remained at a low level. Border Ireland shows approximately 3% of the past cross-border health budget spent on such activity.

However there is an increasingly mobile population on the island, especially in the border region.  Available statistics suggest that approximately 18,000 workers, 5,200 students and 4,000 migrants cross the border to work or study each year, with another 1.7 million crossing to shop or for other purposes by bus or train. There are nearly 14 million car crossings of the Killeen border crossing between Newry and Dundalk every year ¹³.   It is no surprise that cross-border co-operation is most intense in the Donegal region.  The 2006 Irish census showed that there is significant inward migration from the UK, particularly in Donegal where the proportion of UK born residents per constituency was 17.07% for Donegal North-East and 14.17% for Donegal South West.  Donegal’s rural character and proximity to a significant urban centre such as Derry make it an inevitable commuter catchment area.  Unsurprisingly there is a high rate of Donegal workers who compute across the border for work.  Again in the 2006 Irish census Donegal accounts for 59% of all ‘northbound’ cross-border commuting and in some geographic areas over 10% of the local population were commuting to Derry (For example, in the town of Kilderry, 21% of residents commuted to Derry for work).

A North South Ministerial Council initiative, the Border People website (www.borderpeople.info), is helping to document the complexities of being mobile on a small island and having to interact with two health systems.  Managed by the Centre for Cross Border Studies this website provides information and clarity on cross-border issues directly for those people who  cross the border to live, work or study or those who have a foot in both jurisdictions.  It has an integrated cross-border advice service run by the Citizens Advice Centre and the Citizens Information Board under their Borderwise Project.

Photo 1. Advertising Border People website on cross-border routes

For example, take the example of a man who lives in Donegal but works 3-miles across the border in Derry.  Access to the NHS (the UK National Health Service) is based on residency in the UK and funded by National Insurance contributions.  However for the Northern employee who lives in the Donegal (i.e. non-resident) there is no choice of opting-out of paying NI contributions.  This creates a disparity where the people who spend the money have a different set of rules from the people who collect the money.  The EU has partially addressed this by introducing a Regulation stating that a frontier worker is entitled to receive benefits in the country in which they are employed as though the person concerned was resident in that country.  Any dependents (i.e. children and partner) of that frontier worker are not entitled to use the NHS despite the payments of National Insurance contributions.

However as an EU frontier worker the Donegal resident and his family are also entitled to medical cards in the South where they reside.  Basically the EU states that a frontier worker is entitled in his/her country of residency to the equivalent of what he/she pays for in the country of employment.  Entitlements to medical cards in the South is means-tested but if the family had no income in the South applying would be a quick and straightforward process.

Another key group of people for who are seeking answers through the Border People service are those people who have paid National Insurance contributions all their working life only to retire across the border to live and find they are no longer eligible for NHS care when they need it most.  In many instances other EU border regions, such as France-Belgium, have granted dual access to both health systems for frontier workers and their dependents and for retired persons but this has not been considered on the Irish border

ARE WE THERE YET?

While we are on the right path we still have a long way to go.  The existing practice in both jurisdictions of extending services to reach the border has not yet embraced the possibly of integrated cross-border services driven by geography and economic efficiencies.

There are numerous challenges which still need addressing in order to reap the potential benefits of co-operating in health.  Among the most urgent is the need to facilitate flexible funding arrangements for cross-border health care.  It is clear that -border cooperation has to be reciprocal rather than seen as a “one-way street”. That requires both jurisdictions to have funding flexibility and the capacity to facilitate it. If the two governments are keen to exploit the putative advantages of cooperation, one option previously suggested would be to open up competition by creating a fund (or in the Republic of Ireland increasing the resources available to the National Treatment Purchase Fund) to facilitate contracting for elective surgery, either within or across jurisdictions.

The Centre sought to stimulate the debate and provide an independent perspective on hospital planning on the island by commissioning a comparison of strategic policy, North and South ¹⁴ and secondly an associated all-island spatial planning modelling exercise ¹⁵.  The comparative work clearly showed the potential, and the difficulties, of cross-border co-operation in hospital care and outlined clear scope for hospital planning and rationalization exercise in the border region.  The spatial model identifies the location of areas close to the border where people could access hospital services across the border quicker than those in their own jurisdiction.  A full 26% of border residents were disadvantaged by fifteen minutes or more.  Put bluntly, for someone suffering a heart attack or in a road traffic accident, this ‘border factor’ difference could make the difference between life and death.  The map below demonstrates where exactly these zones are.  People living in North Donegal in the Inishowen peninsula and in South Donegal near Pettigo could travel to hospitals in Northern Ireland faster in an emergency.  Likewise people living in West Tyrone would get faster access to emergency care in the Republic of Ireland.  Other areas where travel to hospital distances would be decreased by allowing cross-border access include North-West Cavan along the N87, in the Cooley Pennisula and along the Northern Ireland border with Monaghan in areas such as Aughnacloy, Roslea, Keady and Crossmaglen.  (This will change with the reforms in the NE region and we are hoping to have maps which show access under the new recommended arrangements).

Map 2.  Impact of the border – Prepared by the National Geocomputational Centre, NUI Maynooth

THE FUTURE

The cross-border health debate is much wider than the island of Ireland.  In July 2008 the Welsh Affairs Committee published an interim report setting out key criteria to which the health policies of the UK Department of Health and the Welsh Assembly Government ought to aspire in order to meet the needs and expectations of cross-border health service users.  This report proposes that a permanent protocol on commissioning and funding of cross-border health services would provide greater assurance and clarity to patients and would address current tensions.  A full report is due to be published in autumn 2008.  The Chairman of the Welsh Affairs Committee, Dr Hywel Francis MP, said “The heart of the matter is that Welsh and English patients living close to the border must have access to excellent services as close to their homes as possible, and that the border is not regarded as a barrier in terms of access for these patients.  This is the same vision that the island of Ireland should aspire to for its resident population.

The debate on cross-border health care is also linked to a wider set of issues about the future of European health systems. Recent discussions have highlighted a range of ways in which European collaboration can bring concrete benefits to the effectiveness and efficiency of health services across Europe ¹⁶. This includes collaboration to make better use of resources, developing a better understanding of the rights and duties of patients, sharing spare capacity between systems, mobility of health professionals, identifying and networking European centres of reference, and coordinating assessments of new health technologies. It also covers improving information and knowledge about health systems to provide a better basis for identifying best practice, and ensuring universal access to high quality services.  Both long-standing borders such as France-Spain and the Rhine triangle (France, Germany, Netherlands, Belgium, Luxembourg) but also newer ones that postdate partition in Ireland, such as Slovenia and Estonia, have gone much further than the island of Ireland to develop co-operative arrangements ¹⁷. Here, they have overcome the obstacles to inter-operability through a combination of inter-governmental agreements, integrated health zones, common entitlement cards and 15/25 rules, opening services to people up to 15km or 25km on the other side.

Furthermore on 2 July 2008, the European Commission published a proposal for a Directive on the cross-border provision of healthcare services in Europe, as part of its Renewed Social Agenda.  The aim of this directive is to codify and clarify the rules that have already been set down by the European Court of Justice on patients’ rights to receive healthcare in another European Member State.  It will also make clear who is responsible for quality and safety of care in cross-border settings. Finally it will strengthen cooperation in different areas, such as networks of centres of reference for specialised care.  A Commission healthcare spokesman, Nicholas Fahy said it could take three years for the draft directive to become law through the EU co-decision process and “there is much discussion yet to be had over the details”.

Closer to home cross-border health care will feature on the Autumn agendas of various official committees.  The North South Ministerial Council will meet in Health and Food Safety sectoral formats for the eight time in October/ November 2008.  The Joint Committee on the Implementation of the Good Friday Agreement, a joint Dail (Irish parliament) committee which allocates speaking rights to Westminister MPs, has also timetabled an Autumn discussion on cross-border health care with invitations to be extended to the two Health Ministers, Mary Harney and Michael McGimpsey. Encouragingly the Department of Health and Children (Ireland) and the Department of Health, Social Services and Public Safety (NI) in partnership with CAWT are now preparing an All-Island Health Feasibility Study.  In 2007 in the midst of parallel public sector reform programmes the first joint meeting of the Departmental Board of the Northern Health Department and the Management Advisory Committee of the Southern Health Department took place in Belfast and agreed to consider a more strategic approach to health co-operation.  This is the first time that policy-makers in both jurisdictions have engaged in deep thinking about how to cultivate a genuinely common all-island approach to health.  It is anticipated that the Study will outline a number of specific collaborative projects, identify possible areas where research into potential benefits could be conducted and outline possible constraints to pursuing co-operation.  It is prudent to note that the economic climate in both jurisdictions has changed considerably since this study commenced and this will undoubtedly have a bearing on any recommendations.  The final report is eagerly awaited and will set the tone and the pace for future co-operation by establishing a framework for health co-operation with a planned programme of activity over the next 2-3 years.