Professor Anne Matthews:

I wish to start by thanking the Chairmen, Deputies, Senators and Members of Parliament for the opportunity to attend the committee. I am a full professor for nursing and associate dean for teaching and learning at Dublin City University, DCU. My own background is in midwifery, nursing and social policy.

In 2021, I was delighted to be asked to write a response to an article by Professor Heenan on cross-Border co-operation on health in Ireland, with a particular focus on responses to the pandemic in both jurisdictions. I entitled my response to Professor Heenan's article "A Crowded Stage", as she had noted healthcare had moved centre stage and that the pandemic had provided a case study for research into the politics of health. We both highlighted the unique, specific political context of the time, including Brexit and the then recently restored Assembly and unprecedented Irish Government arrangements following the general election of February 2020. The practical barriers to co-operation amplified during and by the pandemic related to differences in healthcare structures and systems, and limitations related to data were also acknowledged.

Both healthcare systems faced and continue to face considerable challenges, as Professor Heenan has mentioned, such as staff shortages, lack of capacity in specific specialist areas and difficulties meeting primary care needs, though based on different models of provision. In that regard, in 2021, I noted that Sláintecare had promised the delivery of a universal healthcare service to all in the Republic with slow but gradual implementation. The limits to the NHS were and can still be seen but remain in sharp ideological contrast to the historical development and legacies of the Irish health system, which still lacks universal primary care eligibility and a strong public-private divide. At present, only an approximate 43% of people in the Republic have access to free general practitioner visits or free primary care based on age criteria or means testing, with 42% holding private health insurance. The latest Sláintecare 2025 plus plan commits to reviewing eligibility, with a gradual increase for free GP care while building capacity and infrastructure. This remains a considerable implementation challenge.

Covid-19 was a public health emergency and it highlighted acute health service capacity challenges, for example, in critical care. I note the recent appearance at this committee by the Institute of Public Health representatives and agree on the importance of health inequalities and pressure from social, political and, increasingly, commercial determinants of health highlighted across alcohol, gambling and other areas they mentioned. Recent research from the ESRI also highlighted a growing gap in health outcomes, with lower life expectancy and higher infant mortality in Northern Ireland, which the ESRI says reflects the divergence in living standards, particularly income-related, and access to services. The institute also highlighted the problematic lack of good public health data, which Professor Heenan had previously and again noted today. These challenges endure and are likely to hamper responses to future public health threats. It is also useful to note there is currently an evaluation of the response to the pandemic in the Republic and the UK Covid-19 inquiry findings to further prepare for future responses that, unfortunately, will probably be needed.

When considering cross-Border healthcare, there is an obvious focus on Border communities and their population's healthcare needs. There have been several effective initiatives that have already been called out in cardiac, paediatric and ambulance services, with accident and emergency services having been called out specifically in the Good Friday Agreement itself. Another aspect of cross-Border healthcare is the provision of services in one jurisdiction for patients in the other. There have been successful examples of this, including by private providers, with all the caveats involved there.

Notwithstanding these successes, there are limits to both types of activity when both health systems are under pressure, with the demographic factors driving increased demand on both systems. There has been an increase in North-South research covering health topics, including by Professor Heenan, which is useful, and frameworks are in place at that fundamental level for greater healthcare co-operation. It is therefore welcome that this committee has chosen to prioritise this area in its current work plan and I am delighted to support this in any way possible, with the ultimate goal of improving population health outcomes.