Oireachtas Joint and Select Committees

Thursday, 6 February 2014

Joint Oireachtas Committee on the Implementation of the Good Friday Agreement

North-South Co-operation on Health and EU Directive on Patients' Rights: Department of Health

10:10 am

Photo of Joe McHughJoe McHugh (Donegal North East, Fine Gael)
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I welcome from the Department of Health Ms Bairbre Nic Aongusa, assistant secretary; Mr. Paul Barron, assistant secretary; Ms Audrey Hagerty, principal officer; Mr. Charlie Hardy, principal officer; Mr. Tom Monks, assistant principal officer; Ms Louise Kenny, assistant principal officer; Mr. Keith Comiskey, assistant principal officer; and Ms Helen O'Brien, higher executive officer. I look forward to our discourse on the development of North-South co-operation in the health care sector, which affects many people and how the EU director on patient mobility will impact on how patients access services in the future.

I advise witnesses that they are protected by absolute privilege in respect of utterances at this committee. However, if they are directed by the committee to cease making remarks on a particular matter and continue to do so, they are entitled thereafter only to a qualified privilege in respect of their remarks. Witnesses are directed that only comments and evidence in respect of the subject matter of this meeting are to be given and are asked to respect the parliamentary practice to the effect that where possible, they should not criticise nor make charges against a Member of either House of the Oireachtas, a person outside the Houses or an official by name or in such a way as to make him or her identifiable.

The committee would like to explore new opportunities and would like the meeting to be as engaging as possible. We are not here to scrutinise ongoing work. We are interested in what opportunities exist in proper North-South health care provision, which are practical, pragmatic and sensible and which follow common-sense protocols. I call Ms Nic Aongusa to make her presentation.

Ms Bairbre Nic Aongusa:

I thank the committee for inviting the Department to outline and discuss North-South co-operation in the area of health. Co-operation in this area makes sense because the challenges facing health and social care providers, planners, and policy makers on both parts of the island are similar. There is no doubt that patient benefits will accrue from pooling expertise, resources and exchanging good practice. The Department of Health is committed to strengthening and growing North-South co-operation in this area. Members will also be aware that both Ministers for health meet under the auspices of the North-South Ministerial Council, NSMC, to discuss and share experiences on a wide range of issues. This spirit of co-operation is in evidence through the work of Co-operation and Working Together, commonly known as CAWT, which is delivering a number of cross-Border health and social care projects in association with the health and social care services in both jurisdictions and also with the support of EU INTERREG funding.

The HSE, as the key agency with responsibility for the delivery of health services, is proactively involved in the development of linkages between the services here and in Northern Ireland. The executive has a small number of personnel designated to lead on this work and to assist with establishing contacts between individual services in both jurisdictions. This work is greatly supported though the HSE's active participation as a leading partner in the CAWT organisation. The HSE and CAWT, with the involvement of the Department of Health, Social Services and Public Safety in Northern Ireland and the Department of Health work closely with the North-South Ministerial Council on matters of mutual interest to both jurisdictions.

I would like to briefly outline some areas of specific co-operation in health. There is continued engagement between the Department of Health and the Department of Health, Social Services and Public Safety on progressing co-operation in respect of acute hospital services. A clear example of that co-operation was evident in the instant and comprehensive assistance afforded to the HSE and to patients of the north west during the catastrophic flooding of Letterkenny General Hospital at the end of July 2013. The Department of Health has placed on record with the authorities and service providers in the North, in particular Altnagelvin Hospital, its sincere gratitude for that assistance.

The needs assessment of congenital cardiac services on an all-island basis, which is currently being initialised, is a pragmatic example of co-operation across both jurisdictions that seeks to create an effective integrated service for the benefit of patients.

In addition, a working group established by the Department of Health to determine how best to provide emergency aeromedical support to the ambulance service on a permanent basis has, as part of its membership, representatives from the Department of Health, Social Services and Public Safety of Northern Ireland and the Northern Ireland Ambulance Service.

The terms of reference of the group include giving consideration, in the medium term, to the potential for an all-island approach to emergency air medical support.
The committee will also be aware of the proposed new radiotherapy facilities at Altnagelvin Area Hospital in Derry. The Government has committed capital funding for the unit which will offer huge benefits for cancer patients from both jurisdictions requiring radiation oncology services when it opens in 2016. It will improve geographic access to radiation oncology services for over 500,000 people living in the north west of the island. It will also considerably reduce travel times for patients in Donegal and surrounding areas. The project is an excellent example of cross Border co-operation and great progress that has been made to date to ensure the delivery of the new unit. Officials from both jurisdictions are working together on the service level agreement for the operation of the unit.
On alcohol and tobacco, the promotion of health and well-being is very important for all our citizens. There is important and ongoing co-operation between the two jurisdictions on health promotion issues including that of alcohol, which is one of very serious concern. The North-South alcohol policy advisory group, supported by the Institute of Public Health, was set up to undertake work on the issues relating to alcohol availability. This work contemplates examining product, price, promotion, and place, as well as hidden harm, which includes the need to support children with substance-misusing parents or carers. Last October, the Government approved an extensive package of measures to deal with alcohol misuse to be incorporated in a public health (alcohol) Bill. Work is progressing on the development of this legislation which will provide, inter alia, for a minimum unit price in respect of alcohol. This is a mechanism of imposing a statutory floor in price levels per gramme of alcohol that must be legally observed by retailers in both the on and off-trade sectors.
Concrete steps are being taken jointly with Northern Ireland to prepare for the development and implementation of policy on minimum unit pricing. A health impact assessment, HIA, has been commissioned in conjunction with our counterparts in Northern Ireland as part of the process of developing a legislative basis for minimum unit pricing. The assessment will study the impact of different minimum prices on a range of areas such as health, crime and likely economic effects. It is expected that the findings from the HIA will be available by the end of quarter 2 of this year. Minimum unit pricing is key to reducing the harm of alcohol in adolescents and problem drinkers. Collaboration with our colleagues in Northern Ireland on the HIA sets a good example of progress which we can make together in tackling the issue of alcohol abuse. The Minister for Health and his Northern Ireland counterpart are in agreement on the need to act simultaneously to allay concerns regarding negative impacts on cross-Border shopping.
An inaugural North-South tobacco conference was held in Belfast in November last. It provided a platform for speakers, both local and international, to share their experiences and expertise in respect of tobacco control research and policy. Good progress has also been made in respect of standardised packaging and the general scheme of the relevant Bill has been published and has been referred to the Joint Oireachtas Committee on Health and Children. The joint committee called for submissions on the general scheme and the first in its series of public hearings on the matter was held on 23 January. I understand the committee is discussing this matter again today.
There has been significant co-operation between the Public Health Agency in Northern Ireland and the National Office for Suicide Prevention, NOSP, in respect of suicide prevention measures and the implementation of the all-island action plan is ongoing. Particular actions arising from this approach have included understanding risk issues - particularly for young men - the roll-out of applied suicide intervention skills training, ASIST, and the sharing of training resources. As part of its programme of work over the next three years and in partnership with the Department of Health and the health authorities in Northern Ireland, the NOSP will further develop and implement the all-island action plan, focused on knowledge transfer, sharing of resources and information on programmes that are exemplars of good practice. Suicide is a complex issue and there is no single or easy interventions that will guarantee success. However, by promoting cross-organisation collaboration and the development of networks and partnerships we can maximise the impact of our suicide prevention initiatives.
As members are no doubt aware, the Food Safety Promotion Board, or safefood, is one of the six North-South implementation bodies established under the Good Friday Agreement in 1999. It is principally charged with tasks involving food safety awareness, supporting North-South scientific co-operation and fostering links between institutions working in the field of food safety. It has been engaged in a wide variety of projects and campaigns including continuing to support the all-island obesity action forum, the purpose of which is to support the implementation of obesity policies; the "Stop the Spread" public awareness campaign, which was launched in May 2011 to raise awareness that excess weight has become the norm in Ireland and to encourage people to take action; and an independent television production "Operation Transformation", which has been sponsored by Food Safety Promotion Board since 2011.
I am pleased to report that e-health is an area in which we are developing very positive and meaningful relationships with colleagues in Northern Ireland. As part of the Irish Presidency of the Council of the European Union there was very useful co-operation during e-health week in May 2013. The Northern Ireland Minister for Health, Social Services and Public Security, Mr. Edwin Poots, MLA, and his officials were welcome guests at the three-day conference on e-health we hosted in Dublin at that time. The e-health strategy approved by Government and published on 13 of December. It highlights the benefits of e-health from both a jobs and patient-care perspective. We are interested in working more closely with our colleagues in Northern Ireland in this area and we believe there may be potential for an all island approach to e-health. This would have benefits for patients and providers on both sides of the Border.
I am of the view that this short presentation has demonstrated the depth and breadth of co-operation between the two jurisdictions in the area of health. We in the Department of Health will continue to foster that co-operation. While I have attempted to give members a flavour of progress on issues of co-operation, it is not been possible to cover all areas in the time available. My colleagues and I are happy to answer any questions members may wish to pose.

10:15 am

Photo of Joe McHughJoe McHugh (Donegal North East, Fine Gael)
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With the agreement of members, we will take the next presentation before taking questions. Is that agreed? Agreed. I call Mr. Barron.

Mr. Paul Barron:

I would like to provide the committee with a brief overview on the application of the directive on the application of patients' rights in cross-Border health care, more generally known as the cross-Border directive. As members will be aware, the vast majority of patients receive health care in their country of residence. However, in certain circumstances, patients may wish to receive their health care in another country, for example, in the case of highly specialised treatment. The new directive seeks to ensure a clear and transparent framework for the provision of cross-border health care within the EU and EEA. In particular, it aims to facilitate access to safe and high-quality cross-border health care; promote co-operation on health care between member states, while fully respecting their national competencies in the field of health; facilitate the reimbursement of the cost of treatment in another member state; introduce a system of prior authorisation for certain categories of treatment; and facilitate efficient transfer of patient information between member states.

The directive gives people who ordinarily reside in Ireland the option to obtain the health care that they are entitled to under our public health system delivered in another EU or EEA country. The health service provider abroad may be in the public or private sector. The costs will be borne by the patient and he or she can seek reimbursement for the service from the HSE upon his or her return to Ireland. Reimbursement will be equal to the cost of the health care abroad or the cost of similar treatment here, whichever is the lesser. Similarly, persons resident in other EU and EEA states may use Irish health services subject to appropriate referral.

On the transposition of the new directive, there will be two alternative routes for patients who wish to receive planned health care in another member state that will be paid for by the member state in which they reside. The first of these is the long-established route under the relevant EU regulations, commonly known as the E112 route.

The second is the new route under the cross-border directive. The main differences between the two routes are the existing E112 route relates only to treatment provided in the public sector; the treatment must not be available in the health system where the health patient lives; the care must be pre-authorised by the home state; and the costs and reimbursement are handled directly between the home member state and the health care provider abroad rather than between the patient and the health care provider.

By contrast, under the directive there is no requirement for the treatment to be unavailable in the health system where the patient lives, and patients may access treatment in either the public or private sector in another member state. However, patients must pay the health care provider directly for the treatment and then seek reimbursement from the home health system up to the cost of similar treatment in the home state or the actual amount paid whichever is the lesser. Except where the member state opts to have certain treatment subject to a system of prior authorisation, and this power is limited under the directive, the patient is not required to obtain prior authorisation.

Under the directive the member state has obligations to its own residents and to residents in other member states. In the case of Irish residents we must ensure the procedures regarding the use of cross-border health care and reimbursement of costs are based on objective non-discriminatory criteria which are necessary and proportionate; that the procedures are easily accessible and freely available publicly; that requests for cross-border health care are dealt with objectively and impartially; that requests are dealt with in a reasonable period of time, taking into account the specific medical conditions, urgency and individual circumstances of the patient; that decisions regarding the use of cross-border health care and reimbursement are properly reasoned, subject to review and open to challenge in judicial proceedings; and where a patient has received cross-border health care that any necessary follow-up medical assistance the patient may require would be the same as had the patient received the care in Ireland. We must also ensure patients who seek to receive or receive cross-border health care have remote access or be granted a copy of their medical records.

Member states have the option to offer patients a voluntary system of prior notification whereby the patient receives written confirmation of the amount to be reimbursed based on an estimate of the costs. This estimate must take into account the patient's clinical case specifying the medical procedures likely to apply. In the case of residents of other member states we must provide information on request about practical aspects of receiving cross-border health care in Ireland. This includes providing information on treatment options, quality and safety, invoices and price information, the applicable fees, and appeal and redress procedures if patients consider their rights have not been respected. Patients must also have access to a copy of their medical records.

Draft statutory provisions to fully implement the directive here have been prepared and are being considered by the Department. They will then be examined by the Office of the Attorney General prior to settling. Our aim is to have the necessary statutory provisions in place before the end of the first quarter of this year. In the meantime a national contact point, NCP, has been established in the HSE. The NCP is a key provision of the directive. Its function is to provide information to patients resident here and those abroad considering coming here for services. The NCP will advise on all aspects of the directive, including the terms and conditions for reimbursement of costs and the procedures for accessing and determining entitlements. The NCP has arranged for information on the directive to be placed on the HSE website. I am pleased to answer any questions members may have.

10:25 am

Photo of Joe McHughJoe McHugh (Donegal North East, Fine Gael)
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I thank Mr. Barron. The directive has not yet been transposed into Irish law. Will Mr. Barron give us a timeframe on when this will happen?

Mr. Paul Barron:

Unfortunately we are running a little late. It was due to be transposed at the end of October last, but we did not meet this deadline because of the pressure of domestic legislation. The small eligibility unit I head has been involved in a number of pieces of domestic legislation relating to our health services, some of it quite controversial with regard to private patient charges and changing the thresholds for medical cards for those aged over 70. It has held us up, but our aim is to have the directive fully transposed by the end of this quarter. The HSE has already established the national contact point. Work must be done on pricing procedures. Someone going abroad is entitled to an indication of the level of reimbursement on their return. This means the HSE must have a schedule of prices available for various procedures so patients will know the likely reimbursement on their return and can make decisions accordingly. All of this work is being done in advance of the transposition, which we hope will happen by the end of this quarter.

Photo of Joe McHughJoe McHugh (Donegal North East, Fine Gael)
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To give a practical example, if Deputy Seán Conlan needed his hip replaced he could telephone a private hospital, and not just a public hospital, in Stuttgart, have the operation there, pay for it himself and be reimbursed for the amount it would have cost to have had it done in Ireland.

Mr. Paul Barron:

This is a fair summary. We strongly recommend people go to their GP to obtain an appropriate referral in the normal way. It is the same as here, one cannot just ring the local hospital and state one wants to go in for surgery; one must be referred. In the same way we expect people to be appropriately referred.

Photo of Joe McHughJoe McHugh (Donegal North East, Fine Gael)
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After putting Deputy Conlan on the spot I call on him to speak.

Photo of Seán ConlanSeán Conlan (Cavan-Monaghan, Fine Gael)
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I welcome the witnesses. I represent Fine Gael in the Cavan-Monaghan constituency. I very much welcome the directive on access to European health care services. We are almost 20 years into a peace process and on a practical day-to-day basis there must be benefits from the peace process in health care and education for ordinary residents living in peripheral areas, but this has not been driven fast or far enough. Many people along the Border go to GPs in the North. Those living in Monaghan may go to a GP in Armagh. If an emergency occurs family members must drive them to Craigavon Area Hospital rather than getting an ambulance because the ambulance will not cross the Border. These issues need to be sorted out. They are practical measures which should happen on a day-to-day basis for ordinary residents on both sides of the Border.

While the directive is welcome it is discriminatory because there is inequality of access. People who do not have money cannot avail of it as one must pay upfront for the service. If one has it one will get it, but if one does not one will not. A European directive should not be framed in this directive.

I will give a practical example of what could be done at cross-Border level with regard to emergency services such as ambulances. For many people in Monaghan who attend the GP in Craigavon or Keady in Armagh the nearest hospital is Craigavon Area Hospital. It is important these services are provided. I welcome the air emergency helicopter ambulance which has been introduced as it has been used a number of times and has been very beneficial in the Monaghan area. I commend the HSE for putting the service in place.

With regard to alcohol and drugs, there are Cuan Mhuire facilities in my home town of Ballybay in Monaghan and in Newry. This service is provided by Sr. Consilio who receives no funding from the HSE. The service is badly needed in the area and many of those who attend have alcohol, gambling and drug addictions. They are recovering and may be homeless, but no service is provided by the State in the Border area. A voluntary service provided by Sr. Consilio has had to be put in place instead of having services provided by the HSE, or by the Department of Health, Social Services and Public Safety in Northern Ireland. The service is living on handouts and needs statutory funding from the HSE and the Department of Health, Social Services and Public Safety in Northern Ireland to ensure the service is provided in the Border area. Sr. Consilio would not have needed to open the centre if services were provided by the state on both sides of the Border. More needs to be done.

As a first practical step, the HSE needs to engage with Cuan Mhuire and try to provide it with a service. They are getting some ad hoc funding from the Department of the Environment, Community and Local Government to keep going but there is nothing coming from the HSE. That needs to be addressed immediately.
These are the initial points but I would be more than happy to engage, if I can, on the day to day experience of people along the Border. There was hope 20 years ago that services would be developed - some were put in place at the time between Monaghan hospital, Omagh, Dungannon and Craigavon - but the process must be driven much faster. The idea of cross-Border health services is not an abstract thought but it is a practical daily need of people living along the Border. There must be joined-up thinking. Perhaps a small, dedicated team from both the HSE and the Department of Health, Social Services and Public Safety in Northern Ireland could ensure this can happen. We must remove obstacles so we can achieve a proper level of health care at the nearest hospitals on both sides of the Border.

10:35 am

Photo of Brendan SmithBrendan Smith (Cavan-Monaghan, Fianna Fail)
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I welcome the delegation from the Department and I thank Ms Nic Aongusa and Mr. Barron for their presentations. I agree with Deputy Conlan in regard to the need to improve practical co-operation on a daily basis. Over the years there has been the provision of services by Omagh hospital for Monaghan and a dialysis service from Daisy Hill Hospital for patients in County Louth in particular. That is welcome. The Co-operation and Working Together, CAWT, agreement of July 1992 was the first formal partnership and although there has been co-operation, there should be additional momentum.

For those of us living in the Border area in particular, we are fortunate that a very capable hospital has just been built in Enniskillen. The last time I was there I saw that the potential of the hospital has not yet been maximised. If we take the area of Monaghan, Cavan, Enniskillen and Sligo, there is surely a need to deliver services in the area based on a cross-Border context. If there are additional services or new facilities being provided, does the Department or the HSE consult with bodies or account for the needs of health services in the North? We should not provide additional services or new facilities, such as physical infrastructure, on the basis of just catering for our own population in the immediate catchment area. We must factor in the needs of the patients in the North, where such services are also lacking. I hope that in the context of Sligo, Enniskillen, Cavan and Monaghan, we will maximise the potential of the Enniskillen hospital. Services should be provided in the North and South, and I hope the very dramatically improved relationship between North and South will help provide the needed momentum in the health care area.

Mr. Barron mentioned that the aim is to have the necessary statutory provisions in place before the end of the first quarter. Does this mean they will be operational from the end of the first quarter or is a commencement order needed? Has this directive been transposed into law in many member states? Is it only applicable where a resident of a member state that has already transposed it into law is seeking a service in another member state that has transposed the directive into law?

Photo of Joe O'ReillyJoe O'Reilly (Cavan-Monaghan, Fine Gael)
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I will begin where Deputy Smith left off when he mentioned the Cavan, Monaghan and Sligo area. Before I get into the issue, I welcome our visiting delegations and thank them for the presentation. It is important that we develop services on this side of the Border in our hospitals and there should be a strategy for the Cavan-Monaghan hospital group, as well as Sligo. In my constituency there are the Cavan and Monaghan hospitals, which have services that can be available to people north of the Border. That must be a very important part of our strategy. What is happening in Altnagelvin is good, and I am sure the Chairman is acutely aware of the benefit of that. We have listened to radio programmes for a long time about people travelling on buses to Galway from Letterkenny and Inishowen. These were harrowing stories, so it is a great development. Just as we see the Altnagelvin development, there is an onus on the Department and the HSE to ensure we develop services on our side that will draw patients from the South as well as the North. There must be co-operation on both sides about the use of these services and their rationalisation, etc., and it is important that we gear up the services too.

I am very happy that the congenital cardiac services will be provided on an all-Ireland basis. I, along with the Chairman and others, met a very fine delegation of volunteers in the reception area of LH 2000 who campaigned for this issue, as well as parents of children with congenital cardiac conditions. They were campaigning for an all-Ireland centre of excellence. I am happy about that because I was very impressed with the sincerity of the delegation, and we did what we could at the time by going to the Minister. Will a timeframe be provided on that issue and how will it develop in practical terms? It must be very reassuring to parents with children affected by the issue. I subscribe to what has been said about air medical support, which should operate on an all-Ireland basis. Given the size of the country, it does not make sense that it would be otherwise.

Alcohol has come into a tragic focus in Ireland in the past week with the events surrounding the practice of "neknomination" and the two fatalities connected to it. The other night I saw one or two examples of horrific posts that concerned the practice. In one post there was a seven year old child and a baby in a cot as the people took part in the practice, and I can confidentially direct colleagues to that post if they are interested. It was horrific stuff to watch. It is a major problem. I know it is not on the agenda here but Facebook has a responsibility to take these types of posts off its website. If it cannot do so, it should be shut down. We cannot have it as it is an horrendous practice; it gives a terrible example and has horrendous consequences. Although it is not strictly in today's brief, it underlines the gravity of what has been said by the delegation about alcohol.

I agree about the minimum unit pricing. Will the witness elaborate on how the Department sees that progressing, although I know there is a political dimension to this? Deputy Conlan spoke very eloquently earlier and both he and Deputy Smith could speak about how we have seen cycles over the past number of years. In one period everybody would go north to buy cheap alcohol but in another period they may come south to buy it as pricing changes. People fill their car boots full of very cheap alcohol, so minimum unit pricing is critical. There should also be a standardisation of pricing in the North and South.

We must make it a less attractive product for people. A youngster can go out with €20 tonight and buy four pints of beer in a conventional bar, where he or she would drink them in a social environment. That youngster could with the same money buy 20 cans of lager and bring it home to drink it unsupervised and without any social control. That is what we are dealing with, so it is a very big issue. Whether we like it or not, there is a correlation between pricing, consumption levels and addiction. Will the witnesses comment on how they see the process evolving practically, what is being done and from where progress will come? There is also the issue of tobacco packaging. Empirical findings suggest that if plain and unattractive packing is used, it will have an impact on young people starting to smoke. The Minister is right in going after that issue.

We have heard about other practical issues, such as the doctor-on-call system.

My colleague, Deputy Conlan, might have more specific information on the matter due to his location. My understanding, and please correct me if I am wrong, is that we have not developed a satisfactory doctor-on-call system, north and south of the Border. That should be an area of practical co-operation that we could achieve and that would be efficacious on every level. I ask the delegation to comment on the matter and I am happy to be corrected if I am wrong. I know that it was not the case some months ago and presume nothing has changed. Similarly, we do not have an adequate cross-Border ambulance service. I mean an ambulance that would work in a Border radius area, would pick up people on either side of the Border and be able to travel to Enniskillen, Cavan, Monaghan or whatever is required. That is an important issue.

Obviously the points made on food safety do not merit repeating because they were adequately made. They are also very important points.

I wish to make a general observation. I agree with the colleagues who have expressed frustration with the lack of progress to date in the area. Surely, health is an area that we can achieve co-operation on and should not be so politicised. Health is not about flags or emblems and is universal. Illness is universal and does not respect religious or social barriers. Education is another sector but is much more politicised and problematic. The delivery of health services should be a classic area for co-operation. I know that the Department's bona fides are sound and it wants to co-operate but a lot more should have been achieved. Does the delegation agree with my broad observation that not enough has been done, we could have done a lot more and should quickly make up for lost time?

10:45 am

Photo of Joe McHughJoe McHugh (Donegal North East, Fine Gael)
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I thank the Deputy. I call Dr. Alasdair McDonnell and he shall be followed by Deputy Seán Crowe.

Dr. Alasdair McDonnell:

I apologise for arriving late but I had to travel from the far flung corners of the island. I apologise as well because I could not possibly have the eloquence of my friends from Cavan or even worse my friend from Ballybay but I shall make an attempt.

I am a former GP and warmly welcome the potential for the cross-Border directive outlined by Mr. Barron. It is interesting and exciting and I want to see it in action. I shall be brief and have one or two simple questions. What, in the name of God, is stopping further practical patient-oriented co-operation and health? There is no issue more frustrating for people along the Border than the flexibility on that, in both directions but probably on balance slightly more going North than those coming South. I do not want to incriminate myself too far. I abused the British system for years because I was aware of dozens, if not hundreds, of people from Donegal fabricating an address in the North so that they could access health care. I have never mentioned this before and I do not wish to make a song and dance about it but it was a scandal for all sorts of reasons. That frustration exists. The British side or the British National Health Service has tightened up significantly and has managed to sift all of these people out of the system. Therefore, somebody living in Donegal today has great difficult accessing the North but 15 or 20 years ago - and I do not want to say any detail because probably some of it was slightly fraudulent - people were desperate to access health care. That is not justifiable, whether it is surgery or an item of health care.

The witness wisely mentioned pricing. We know what pricings are here in the VHI system. We know what pricings were in the North under fund holding 15 years ago. We gave up fund holding because the bureaucracy around it was more than the clinical care. It is easy enough to price things. A price can be put on a gall bladder or appendix removal. There is space and accommodation. At times there are queues for some issues in the North but there is always accommodation around the system as well. There is always vacant accommodation around the system.

My colleague here wisely mentioned the Enniskillen hospital. I am very worried about the Enniskillen hospital because it needs more customers, to be put at its simplest. Those customers could be people living in Blacklion or similar places along the Border. It could equally be people in the South and south of Donegal on the other side. It is not beyond the wit of man to get some of this together.

I have a lot of time for Co-operation and Working Together, CAWT, the various organisations, and Mr. Tom Daly and his efforts. From what I have seen, our bureaucracy on both sides of the Border seems incapable of defining the barriers and removing them. Everything is perfect in theory and practice but we do not seem capable of getting it to the final stage and over the line. Nothing would create more satisfaction in people's minds, on both sides of the Border, than opening up flexibility. I shall not go into a ream of detail on the matter but shall suggest one simple thing. There can be a trade-off. People on the southern side of the Border would warmly welcome, as Deputy Conlan has outlined, access to primary care, GPs and similar in the North and early, simple and straightforward secondary care. If it came to a complicated situation there might be a decision made that a person must be referred back to Dublin or whatever.

We have a problem in the North which is being highlighted at the moment by congenital cardiac surgery that you guys are tackling and I thank them for doing so. That could have been tackled a wee bit more sensitively and with a wee bit more political understanding. The initiative is almost over the line, if not over the line already. There is a need for high quality coronary care and there are facilities in the North. The Minister in the North would like to create a second set of facilities around Altnagelvin which would serve Donegal and other areas. That initiative must be got over the line because if one's father, mother, brother or sister is dying with a heart attack one is not terribly choosy as to who will save his life. That is essentially what we are talking about here - getting people in remote rural areas, within an hour or less than hour, to a catheter lab where the clot or whatever is threatening their life can be removed.

Other issues can be traded off in a southern direction. We desperately need a plastic surgical unit dealing with burns. We have a small but very significant number of people, on both sides of the Border, who have been very badly disfigured and scarred. However, we do not have a coherent unit to deal with burns on the island. There are some good people in the North who work at the discipline but they have at least one hand tied behind their backs and the same happens in the South.

There is another issue around obesity. There is a desperate need for an all-island obesity service where surgeons can take out bits of bowel or whatever in order to help those people who are unable to control their weight. I have outlined a number of niche markets and issues where there is no major coherent service, North or South. There can be a coherent service on both directions and must of it can be located in Dublin. It would lead to a win-win situation. As Deputy Conlan suggested, we could have a flow northwards at primary care level and there can equally be the same for highly specialist and niche markets or rare diseases.

I congratulate the delegation. I am not levelling any accusation against any of the people here because I know the work that they have done. We must find the driver, somebody or something that will make more happen quicker because health initiatives should not be so slow. I want to know if there have been issues in the North. I have regular conversations with Edwin Poots. Regardless of politics, he has made it very clear to me that he has signed up for as much cross-Border co-operation on health as he can and it is not a political issue with him but a humanitarian one. Therefore, we must find the ways and means. Are there medical obstacles? Is it the medical profession?

If people are guarding patches, and my guess is that the medical profession have a hand to play in it, we must find some system of moving around it. There are gains for everyone and there are gains for the Department of Health and the Department of Health in the North. I have gone on far longer than I intended but there is an array of issues.

10:55 am

Photo of Joe McHughJoe McHugh (Donegal North East, Fine Gael)
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Yes, Dr. McDonnell did and he said he was going to be brief.

Dr. Alasdair McDonnell:

I was brief. I could have been here until midnight.

Photo of Joe McHughJoe McHugh (Donegal North East, Fine Gael)
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With regard to Donegal, I will not defend the indefensible and I do not do Donegal sensitivity but I came across a statistic yesterday that there are 5,000 frontier workers in the north west. There is quite a lot of mobile occupation and we are nomadic people in Donegal.

Dr. Alasdair McDonnell:

The Chairman does not have anything to defend. People are quite right.

Photo of Joe McHughJoe McHugh (Donegal North East, Fine Gael)
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Mr. McDonnell was using Donegal as an example and there are other counties as well.

Photo of Seán CroweSeán Crowe (Dublin South West, Sinn Fein)
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It is a given that co-operation in health can deliver real benefits and efficiency in the system. Everybody accepts there is goodwill towards the project and no one seems to be opposed to it. There is an argument that it is not delivering the results as quickly as we would like. I would like to concentrate on what Mr. McDonnell refers to as people guarding their patches. If there are difficulties in respect of the system, is there a way of better co-ordinating it? Under the current system, the Ministers meet and the officials meet. Can another layer be established or is there a need for a conference bringing people from medical backgrounds together with those who are concerned with patients' rights? They could look at the gaps in services and what we could do better. Has that ever been done? Would that be a helpful way of moving forward?

Yesterday, a group based in Maynooth, AIRO, made a presentation on its work to map needs and services throughout the island, particularly along the Border. The group focused on the limited number of services and time critical issues such as travel times for accident and emergency cases, coronary care and strokes. Co-operation on these matters is a real benefit for communities. One of the questions is whether the Department works with groups like this to map services along the Border. Does the Department provide support to map services and plan for cross-Border services in accident and emergency, coronary and strokes? We are familiar with the golden hour. How does this operate in respect of choosing between going to Louth hospital or Newry? What co-ordination exists?

Mr. Barron referred to the directive that is to be introduced. Is there anything we can do in respect of the resources? What is needed to speed it up? It makes sense in respect of cross-Border services. Is there something the committee can do if there is a delay?

The witnesses referred to what is available to people, including the E111 card. Is there a difference between jurisdictions? If I travel across the North and I am involved in an accident, I may be provided with services. Is there a difference if a similar thing happens to me in Spain or France? As an example, someone was recently involved in a serious accident in Spain. The person has been sent a bill for €8,000 because the person did not produce the E111 card. The person had it on a mobile telephone but this was not acceptable. The card has to be produced. Are there anomalies in the system that must be ironed out? We can talk about it later.

The witnesses also gave the example of people looking for care outside the jurisdiction. What are the options for people waiting for access to a paying doctor for one and a half years while on all sorts of medication that is making their condition worse? Rather than waiting for a year or a year and a half to see an ophthalmologist in Tallaght hospital, can I opt for this? What is the deadline?

Regarding specialties, do difficulties exist if Crumlin hospital or Newry hospital must upgrade services? If there is a lack of service in respect of certain specialties, what can we do? I am thinking about this committee and trying to encourage the cross-Border element. The witnesses must come back to us with recommendations that we can put forward to change the system. We are not looking for negativity for the sake of it but an improvement to services. That is what we are all looking for.

Photo of Mary WhiteMary White (Fianna Fail)
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I thank the witnesses for attending. In this area of health, progress has been made. Health is more positive than many areas. As Mr. McDonnell said, there must be a key driver of all issues and the opportunities for more co-operation. I am interested in current arrangements for cancer care in the north west. Ms Nic Aongusa referred to this but perhaps she can repeat the point.

Photo of Mary MoranMary Moran (Labour)
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I apologise for being late this morning. Much of what I wanted to say has been said. I welcome the progress made but we have a long way to go. Everyone has goodwill towards this. Like Deputy Conlan, I live along the Border in Dundalk. I do not understand why an ambulance from the North cannot come into the South and vice versa. In emergency care, this point must be addressed.
I refer to the options for people with disabilities to access special care across the Border. This applies to the search for paediatricians. In my area, there is no orthopaedic paediatric surgeon in Our Lady of Lourdes Hospital. It is a centre of excellence, and despite numerous questions I have submitted seeking details, I have yet to receive a response. From sitting in the hospital for up to eight hours waiting for an orthopaedic appointment, I know people can go across the Border and access it more easily and quicker. This is not available to us. What plans exist in this respect? At the moment, the facilities are not in place.

We have spoken about nomadic people with various addresses but I actually know of people whose children have special needs who have moved across the Border. They have upped and moved across the Border because they could access treatment and services in Newry that they could not get in Dundalk. That is appalling and it must be addressed urgently.

I recently dealt with a mother whose son had applied for funding under the treatment abroad scheme for a very rare condition. He had been assessed and accepted by a hospital in England, which would provide the required treatment. When he came back and applied to have that treatment, he was told that the treatment was available in Ireland and his application was refused. What is the criteria for qualification under that scheme? When he checked the situation here, the orthopaedic specialist he saw in Cappagh Hospital told him that he would have to go to England for treatment. He was assessed and accepted for treatment. The witnesses may know of the case to which I am referring. I know the individual returned to England for some treatment but has been experiencing problems again in recent months.

11:05 am

Photo of Frank FeighanFrank Feighan (Roscommon-South Leitrim, Fine Gael)
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I apologise for being late. The former Taoiseach Brian Cowen once referred to the Department of Health as "Angola" because there were so many landmines going off. I appreciate that the witnesses do a great job and work very hard in very difficult circumstances. However, it sometimes seems that the Department of Health, those working for the health services, such as doctors and consultants, and HIQA do not follow up on their convictions and leave politicians holding the line. Perhaps the press does not listen to them but they should state what it the best approach for our health services. It should not be left to politicians to hold the line.

I come from Roscommon and at the mere mention of Roscommon County Hospital, people say "Oh my God". Roscommon county has a population of a little over 50,000, with just over 5,000 living in Roscommon town. Those living in north Roscommon, where I live, travel to Sligo for treatment, while the people of south Roscommon go to Ballinasloe. Therefore, there are approximately 25,000 people living in the catchment area for the hospital. The accident and emergency department at the hospital had no cardiac surgeon, no paediatric surgeon, nobody to incubate and no anaesthetist for overnight cover. How can that be called an accident and emergency department?

I was in Dublin just over two years ago discussing this with representatives of the Department of Health. Everyone told us why the accident and emergency service could not remain in the hospital. The consultants wrote that the department was unsafe. HIQA said that the consultants could not remain in the department because they would be de-skilled. Then all hell broke loose and everyone went to ground. The Department of Health did not get the message out. HIQA decided that it would not follow up on what it had said at the meeting because it did not want to be political. The consultants who wrote the letter said nothing and the GPs and doctors all went to ground. They left this unfortunate politician to hold the line. I know that everyone here will agree, privately, that it was the right decision to make. It would have been crazy to allow the accident and emergency department to remain open. That is irrelevant, however, because the people of Roscommon think that people will die. Nobody has died in two and a half years and at least 50 lives have been saved because there is an air ambulance in place. Paramedics and advance paramedics are saving lives.

The Department and others running our health services must stand up sometimes and not leave the politicians holding the line. I will always be the politician who closed the hospital. The hospital is actually twice as busy. The urgent care centre is as busy as ever and by the time we are finished, the hospital will be five times busier and twice as big. The witnesses here know that and I know that. How can we get that message out? It should not be left to the politicians to hold the line because nobody believes politicians or even wants to believe them.

In terms of the media, both local and national, it is a race to the bottom. They want to report the worst case scenario. I am disappointed in the Department of Health, HIQA, GPs and consultants. There is a saying, "What is the difference between a consultant and God? God doesn't think he's a consultant". The witnesses here have a job to do. I would like to hear their observations on that. What happened was they allowed a vacuum to be filled. I am not blaming them. I am blaming the whole system. I am blaming politicians too. Politicians will try to take credit for some things. They should stand up. We need impartial people to come out and state the facts. That is what happened in Mallow.

The situation regarding the accident and emergency department in Mallow was very similar but three consultants there came out and said that closing the department would be the best move in the context of patient safety. They said that the people should go to Cork, end of story. In Roscommon County Hospital, the three consultants wrote a letter stating that the department was only useful when, probably once in every four years, there might be a car crash within a mile of the hospital. I asked them why they did not say something when 5,000 people were outside the hospital, protesting at the closure of the department. They said it was more than their lives were worth to say something. All I am saying is that the witnesses have a job to do and it is a difficult one. However, there are times when they cannot leave politicians alone, defending decisions.

The air ambulance service is an enormous success and must be retained. Now it is time to get an air ambulance in the North too. The air ambulance from Athlone will cover most of the south. An air ambulance in the North could serve the people north of Athlone. This is cross-Border co-operation that will save lives. It is imperative to examine the possibility of having two air ambulances.

I am sorry to have spoken at length earlier. I was not having a go at the witnesses but was saying that something must happen and the witnesses cannot leave politicians high and dry.

Photo of Joe McHughJoe McHugh (Donegal North East, Fine Gael)
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Members went over time because this is such an important issue. It is also an emotive issue but there are practical solutions to hand. We want to help and we want to contribute. I will give the witnesses an opportunity to respond but before doing so, I wish to acknowledge the fact that 2016 is the target for the opening of the radiotherapy centre in Altnagelvin Area Hospital, which will cater for a catchment area population of 500,000. That is very welcome.
I wish to pick up on a point made by Deputy Feighan and others about paramedic and ambulance cover. I do not know what the situation is in County Louth but I am aware there is good co-operation between Altnagelvin Area Hospital and Letterkenny General Hospital. I am not sure that the public is aware of that, however, so we have a job to do in terms of letting people know the true situation.
I am not seeking a comment on the tragic case of Ms Porter who died at the side of the road in Carndonagh, having waited for 50 minutes for an ambulance, because that is currently the subject of a HIQA inquiry. I welcome the fact that such an inquiry is taking place. A few miles down the road from that incident, however, there were ambulances at Altnagelvin. There were also ambulances outside Letterkenny General Hospital but Ms Porter's family could not get an ambulance for their mother, who was dying at the side of the road. On top of that, the helicopter service was en routefrom Malin Head to Sligo at that time. There are opportunities for joined-up thinking.
The Minister for Health is on record speaking about the potential for Enniskillen, Sligo, Altnagelvin and Letterkenny to co-operate in the context of air ambulance and paramedic services. I invite the witnesses to comment on that. What is the current standing of the proposal in the Department? Sometimes we as politicians talk about cross-Border co-operation as if it is a simple matter. At a political level, the Health Minister, Mr. Edmund Poots MLA, and the Minister for Health, Deputy Reilly, are working together and agreeing solutions but sometimes the implementation proves difficult. Perhaps the witness could elaborate on the difficulties they are encountering. Are there turf wars or cultural barriers? Is it the case that people have a difficulty with doing something new? Is it down to the human condition? Are we creatures of habit, used to doing things in a certain way? The witnesses are responsible for the Twenty-six Counties.

What are the difficulties and what are the barriers to the common-sense practical solutions we naive politicians think should happen in the morning? This may be something we need to find out. I thank the members for their contributions and leave the last analysis and feedback to our guests.

11:15 am

Ms Bairbre Nic Aongusa:

I am the senior person in the Department of Health with overall responsibility for North-South co-operation. As is evident from the discussion, the areas of co-operation span many parts of the Department. Therefore, in a few minutes I will ask my colleague, Charlie Hardy, a principal officer in the acute hospital division, to deal with some of the issues committee members have raised about emergency and hospital services. Issues were raised also about GP cross-Border services, and my colleague, Paul Barron, will deal with those. He will also cover the various issues relating to the cross-Border directive.

I will take a few minutes to deal with some of the other issues. A general question raised by a number of members, including the Chairman, concerns the fact that while there is significant good work under way in cross-Border co-operation on health, there is much more that could be done. The Department of Health would agree with that. There is very close co-operation at official level between our Department and our colleagues in the North. The Secretary General of the Department meets his counterpart in the North, Andrew McCormick, regularly - several times a year. There are also regular meetings at official level across the spectrum of North-South issues.

A question arose as to whether there is a process by which new areas of co-operation can be explored, other than through the usual liaison between officials. Deputy Crowe mentioned conferences and special events. We have done that in the past and would consider doing it again. I mentioned the successful cross-Border conference on tobacco. We also had one on e-health in Dublin during our EU Presidency, on which we had very active engagement from Minister Poots and his officials. Under the formal mechanisms, the parties involved are in regular contact to decide on priorities. At the most recent North-South Ministerial Council plenary session, it was agreed there would be an exploration in each sectoral area to establish whether there were additional priorities that could be progressed. That exploration will take place in the health area and we will certainly take into consideration the various issues raised here in this discussion.

The issue of alcohol was raised and there were questions and concerns about minimum unit pricing. We have a North-South alcohol policy advisory group in the Department, which was set up by the chief medical officers of both jurisdictions in 2012. This group has been doing significant work on assessing the evidence for the alcohol policy that has been agreed. The Government has approved an extensive package of measures to deal with alcohol misuse, including the drafting of the public health (alcohol) Bill which will include provisions for minimum pricing. Concrete steps are being taken to address concerns about minimum pricing.

I mentioned research that has been commissioned, in conjunction with the Department of Health and Public Services in Northern Ireland, to model the impact of the minimum unit pricing on alcohol consumption in both jurisdictions. As well as looking at the health impacts of alcohol consumption, the impact assessment is being required to look specifically at the likely effects of different minimum prices on a range of areas, such as crime and the economy North and South. A Sheffield university has been awarded the contract to carry out the wide-ranging impact assessment, and it is anticipated the research will be ready by the end of quarter two of this year. I expect the study will address some of the concerns people have had about the economic effect and, possibly, the effect on levels of crime in Border areas.

Minimum pricing is a tool which addresses the issue of alcohol that is cheap relative to its strength, and all the evidence has shown that its use is more effective in terms of targeting at-risk drinkers, particularly young people. Some committee members mentioned the recent controversy concerning the so-called Neknomination. Young people are attracted to buying cheap alcohol at very low prices, and minimum unit pricing has been shown to be the most effective way to deal with that. It is more effective than increasing excise duty across the board in terms of addressing this issue.

Senator White asked about the cancer radiotherapy centre in Altnagelvin. That unit is due to open in 2016 and the Irish Government has committed once-off capital funding of a ceiling of one third of the cost for radiotherapy facilities at the centre. The unit will provide access to radiotherapy services to more than 500,000 people. Approximately 10% of patients from the Republic will continue to receive more specialist treatment in Galway or Dublin. Republic of Ireland patients receiving radiotherapy in Altnagelvin will continue to have their diagnosis, surgery and other treatment planning in either Letterkenny or Galway. Agreement was reached with the Northern Ireland authorities on the revenue costs, and discussions are under way for a service level agreement which will finalise the agreement between the two jurisdictions for the radiotherapy services to be provided in Altnagelvin. This is very much a success story in terms of North-South co-operation.

Photo of Mary WhiteMary White (Fianna Fail)
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What is the current situation? The current need for people from Sligo or Donegal to travel to Galway is very controversial. What is the current position regarding somebody in Donegal?

Ms Bairbre Nic Aongusa:

I have a note from my colleague on this. Currently, there are cancer centres in Dublin, Cork, Limerick, Galway and Waterford and an outreach service in Letterkenny for breast cancer. Patients from the north west are seen in the appropriate centre, depending on the particular cancer. For example, radiotherapy centres are provided in St. Luke's Hospital. Currently, a consultant from St. Luke's visits Letterkenny once a week and refers patients to the St. Luke's network, which is St. Luke's, Beaumont and St. James's hospitals. When the Altnagelvin unit is opened, patients from the north west will have access to that unit.

Photo of Mary WhiteMary White (Fianna Fail)
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Is it correct that when that is up and running in 2016, it will treat 500,000 patients, 10% of whom will be from the Republic?

Ms Bairbre Nic Aongusa:

No. It will provide access to radiotherapy services to more than 500,000 people in the north west, but a small number, approximately 10%, will have to continue to receive more specialist treatment in Dublin. Approximately 90% of patients in the north west will be able to avail of facilities at Altnagelvin.

Dr. Alasdair McDonnell:

Is any consideration being given to providing for women with breast cancer or others, such as men or women with bowel cancer, at Altnagelvin? By the time they require radiotherapy, they are at the start of a slippery slope. Perhaps they will get better, but when people need radiotherapy, it is usually because the cancer has spread. What are the chances that these people will be able to access surgery in Altnagelvin or elsewhere at some stage? There is a world class cancer centre in Belfast. Professor Patrick Johnston, a proud son of Derry and soon to be Chancellor of Queen's University Belfast, effectively set up that centre. What are the chances of tapping into that resource? If somebody has a tumour, the sooner he or she has surgery, the better. I do not suggest they should wait for treatment in the North, but surely it is worthwhile trying to access any space available for surgery in the North, rather than wait six weeks or three months to have surgery in Galway, Dublin or somewhere else. How soon treatment or surgery can be started is a vital issue for people who are diagnosed or whose relatives are diagnosed with cancer.

Ms Bairbre Nic Aongusa:

The whole area of North-South co-operation is one that can be expanded on and developed. It is a step-by-step process. A very good example of how this can be done is the radiotherapy centre in Altnagelvin.

I will hand over to Charlie Hardy in a moment to talk about the other work that is under way in the hospitals area. There is huge potential there as we continue to strengthen the links at official level. I mentioned that our Secretary General meets with his counterpart but I also know that our chief medical officer, Tony Holohan, has a very good working relationship with his counterpart. Our chief nursing officer, Siobhan O'Halloran, has a very close working relationship with her counterpart in the North. This is a work in progress. We will continue to work to foster and develop those links and look at other services that can be developed. I will hand over now to Charlie to talk more about the hospital issues.

11:25 am

Mr. Charlie Hardy:

Recent developments in the State have been moving towards the organisation of hospital groups, leading to hospital trusts. The report was written by John Higgins who happens to be a Tyrone man working in Cork. He is well aware of the North-South dimension. Built into the report was the need to ensure that in strategic plans for the bigger groups there would be North-South co-operation and networking of hospitals across the Border. I do not think there will be cross-Border groups or trusts at this stage but networking across the Border is a very important element of the strategic plans the groups are being asked to draw up in the next few months. A strategic advisory group is meeting as we speak. John Higgins is part of it and it will look at the services generally. That is something will be kept on the agenda. We will build on the work of Co-operation and Working Together, CAWT. In the past there were very good examples of cross-Border co-operation and they will be built into the strategic plans of the groups, in particular those groups relating to the north east and west north-west, which are conjoined with the Border. As well as that, there is a proposal to draw up a steering group between the two Departments to deal with hospital co-operation in particular. We will work with colleagues in Northern Ireland to set that up in the future. That will give some element to the co-ordination to which reference was made.

As regards the emergency ambulance situation, I know that calls have been made across the Border to the North and the South for ambulance transfers in emergency situations. There are developing links and good communication in many areas on that and the National Ambulance Service is anxious to improve on the links and will work to do that as much as it can.

The aeromedical service has been very successful, as Deputy Feighan acknowledged. It is being reviewed at the moment. We hope to enable it to continue in the best way alongside the proposal that has emerged for a northern aeromedical service that will be complementary, exactly as has been described. The discussions are at an early stage at this point. The policy in the North was not to have an aeromedical service but the view on that has changed and we are working together to see whether we can have a joint aeromedical service to complement the service being established in the State as well. That will be very positive, in particular for Cavan, Monaghan and Donegal.

Again, in the north west we have heard about Altnagelvin but there are also proposals on the table for north west cardiology. When Bill Maher, the CEO of the west north-west group, and his chair, Noel Daly, went to Altnagelvin to thank them for all the good work they did to assist when the flood took place in Letterkenny they raised the issue again. While resources are very tight and it is very difficult to carve out resources to make progress in many of those areas at the moment, they are working with colleagues in Altnagelvin to see how that could be advanced as well. There will be no change in any service in that area until it has been put in place and piloted and we can see what the results are on a broader front. Again, that would apply to the group plans that have been put in place there too.

Reference was made to congenital cardiac surgery and paediatric cardiology. That has been worked on for a long time and there has been good co-operation. Up to 29 cases involving children from Northern Ireland were treated last year in Crumlin hospital in Dublin. They are working on a new service level agreement as an interim measure to deal with the service west. An internationally-led expert assessment is to take place, which is due to finish at the end of June. The assessment will describe the existing hospital services in both jurisdictions, outlining options for service configuration and governance arrangements. The experts will report to both Ministers jointly and recommend an approach to an appropriate model that meets the population needs and other requirements in both jurisdictions. We can expect a report from the internationally-led group, which is well supported in terms of the requirements it needs to bring the report forward.

In addition, we have looked at the situation in Enniskillen. We think there is great potential for cross-Border co-operation with that hospital. There will be two-way traffic. We are determined to try to ensure that two-way traffic takes place and that everybody gains the maximum from the situation.

I will take back the ideas that were spoken about in terms of obesity services, the paediatric surgeon and other ideas. I can feed them back into the system in terms of considering the strategic options and the group strategic plans that will be brought into play in the next few months. That generally covers the issues. I will come back if anyone wants me to follow up on any issue.

Photo of Mary WhiteMary White (Fianna Fail)
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From listening to what we have heard today, is it not correct to say that two political drivers are needed; one in the North and one in the South to drive through the common sense issues raised by Alasdair McDonnell, MP? He is on the spot and he knows. We need the drivers to be in place. With all due respect, reports and meetings between the Secretary General and his counterpart mean nothing. Both Ministers must have the bit between their teeth to make this happen.

Photo of Maurice CumminsMaurice Cummins (Fine Gael)
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They have to have the money to do it as well.

Photo of Mary WhiteMary White (Fianna Fail)
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Gabh mo leithscéal-----

Photo of Joe McHughJoe McHugh (Donegal North East, Fine Gael)
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I am conscious that we have another presentation.

Photo of Mary WhiteMary White (Fianna Fail)
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I am only making the point but I got interrupted by the interjection of the Leader of the Seanad. My point is that the Ministers have to do it. I refer to what Alasdair McDonnell, MP, said about the Belfast hospital being able to help the people in the north west. We have to do something about it. We hear about the implementation of the Good Friday Agreement-----

Photo of Joe McHughJoe McHugh (Donegal North East, Fine Gael)
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In fairness, there is a conflict of interests.

Photo of Mary WhiteMary White (Fianna Fail)
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It is frustrating.

Photo of Joe McHughJoe McHugh (Donegal North East, Fine Gael)
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Of all the joint ministerial representations North and South, the most high profile public advocates of pragmatic cross-Border co-operation are the Health Minister, Edwin Poots, MLA, and the Minister for Health, Deputy James Reilly.

Photo of Mary WhiteMary White (Fianna Fail)
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Yes, but what about all the issues Alasdair McDonnell, MP, raised?

Photo of Joe McHughJoe McHugh (Donegal North East, Fine Gael)
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I am conscious of the time. I call Mr. Barron.

Mr. Paul Barron:

I am conscious of time also. A number of questions were raised about the EU directive so I will try to deal with them as quickly as I can. There were also questions on cross-Border GP care, which also falls into my area.

Deputy Conlan suggested that the directive is discriminatory. The directive is European legislation not domestic legislation. If it is discriminatory it is not because the State wants to have discriminatory legislation. In my opening remarks I very briefly compared and contrasted the two routes, as I described them. It is fair to say that the new route under the directive might not suit everyone because it involves one having to pay upfront and seek recruitment. I take the point that it might not suit on every occasion but the other route still exists – where one does not have to pay upfront – albeit one is limited to availing of public facilities rather than private facilities. There is good and bad in respect of each route. One of the important roles the national contact point will play is to provide advice to people so that they can make decisions as to which route they wish to follow.

Deputy Smith inquired about my commitment to the end of the first quarter. The intention is that at the end of the first quarter we would have full implementation and that on or before the end of the first quarter the Minister would sign the commencement order and then we are in business. There would not be a further lead-in period. Hopefully, from the beginning of the next quarter we will be up and running legislatively.

Deputy Smith also inquired about the number of member states. To the best of our knowledge, as of the end of last year, only seven member states out of the total had transposed the directive. That is no excuse for us not having done so but the fact of the matter is that only seven member states have so far transposed the directive. Our understanding is that the UK transposed it at the very end of December. Deputy Smith then asked a supplementary question on the position whereby some countries have transposed the directive and others have not.

The position at present is that it is not open to residents here to avail of the directive and to go abroad because we do not have a system in place to enable them to be recouped. However, for those countries that have transposed, it is open to their citizens to come here because their home member state will recoup them. Consequently, until such time as we have transposed, it is not open to people here to avail of the provisions of the directive, unfortunately. There have been a small number of inquiries to the HSE and the position has been explained to them. Our understanding is that people are prepared to wait for the few weeks until the directive comes into operation.

Deputy Crowe kindly asked whether there was anything the joint committee could do and we are grateful for the offer. The position is that through no fault of our own, there was pressure of business following on from the Presidency and so on and we had a backlog of legislative work. Much of that backlog now has been cleared and while a number of issues are ongoing, this one is very much a priority. We have engaged a legal draftsman to help us and the matter is very much in train. As I stated, we hope to have the directive transposed by the end of the quarter. Consequently, while we are grateful for the offer, I do not think any further assistance is required at this stage.

The Deputy also asked about differences between countries and I suppose an important point to make is that what I described this morning are two routes for people to avail of elective treatment abroad, whereas the Deputy's example pertained to an emergency situation. Generally speaking, such emergency situations in the European Union are dealt with under what used to be known as the E111, and which now is known as the European Health Insurance Card, EHIC, which sits beside the two routes. It is getting complicated now, in that there are two routes to avail of elective treatment abroad and then in addition, the EHIC is there to assist if one is on holidays or whatever abroad. My colleague, Mr. Tom Monks, sits on a European grouping that oversees these various measures and it appears as though there can be difficulties in certain jurisdictions, Spain being one of them. If the Deputy has a specific case in mind, we might be able to provide him with some assistance.

Senator Moran raised a specific case and while we are not familiar with the case in question, we would be happy to talk to the Senator about it. One condition that applies at present is that a person going abroad under the current E112 arrangement must have sign-off by the Irish consultant. I do not know whether that arose in this case but we can talk to the Senator about that. Some questions in respect of GP out-of-hours services were raised by Deputy O'Reilly and Mr. McDonnell - I am unsure whether he has any other designation. Our estimate is that in the case of approximately 65,000 people, their nearest GP out of hours is across the other side of the Border. Consequently, a pilot project allowing patients in Inishowen to attend out-of-hours GP services in Derry came into operation as long ago as January 2007. A second pilot project, allowing people resident in south County Armagh to obtain the service in Castleblayney, commenced in November 2007. Since commencement and up to 31 December 2013, approximately 700 patients from Inishowen received services in Derry, which is an average of approximately eight per month, while 2,300 patients from south County Armagh received out-of-hours services in Castleblayney, which is an average of approximately 32 per month. Both jurisdictions are involved in monitoring this on an ongoing basis. There were proposals to extend the trial to cover Blacklion, County Cavan, and Pettigo, County Donegal, to assist people on the opposite sides of the Border. Initial discussions took place with local GPs but there did not appear to be a great deal of interest. However, if there is a particular interest in it, we would be happy to take this up again.

11:35 am

Photo of Joe McHughJoe McHugh (Donegal North East, Fine Gael)
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I thank Mr. Barron and I am conscious that Ms Gildernew wishes to make a brief contribution.

Ms Michelle Gildernew:

I apologise for being late and for missing the presentation. I acknowledge much work has been done and am aware of the work of Co-operation and Working Together, CAWT. However, there is much greater scope for more work and for cost-saving were this to be done right. In the Assembly this week, my colleague, Phil Flanagan, raised the issue of how Enniskillen hospital could be better used in bringing services to it. Have there been discussions on the island of Ireland about the health implications of fracking, if that is introduced? My constituents in County Fermanagh, together with people in counties Leitrim and Cavan, are extremely concerned about the environmental and health implications of that process, if the earth is broken and benzene and other chemicals are allowed to get into the air or the water table. Have there been discussions on that issue?

Ms Bairbre Nic Aongusa:

I am afraid I do not have that information to hand the present. However, I can check with the office of the Chief Medical Officer and communicate with Ms Gildernew directly.

Photo of Joe McHughJoe McHugh (Donegal North East, Fine Gael)
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I thank the delegation who have shown commitment to cross-Border co-operation. While one can get caught up in issues concerning quality, quantity and so on, the wide range of people who are present in today's delegation is a sign to members that the Department is committed to the process. A range of issues exist, such as the provision of paediatric cardiology in Belfast and Dublin, and loads more questions remain. However, it is good to have a point of contact, even today. Can the joint committee liaise with Ms Nic Aongusa if issues arise? Is it okay for the joint committee to use her as a point of contact in respect of health issues?

Ms Bairbre Nic Aongusa:

That is fine.

Photo of Seán ConlanSeán Conlan (Cavan-Monaghan, Fine Gael)
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As for what has been said regarding cross-Border co-operation in health care, one practical consideration is there must be a tie-up between the Departments of Health and Transport, Tourism and Sport on the development of the road infrastructure between counties Monaghan, Cavan, Fermanagh and Armagh, because at present it is atrocious. Over the past 40 years, this infrastructure has never been developed and to get from one county to another at present is a nightmare. That must be developed in co-ordination between the aforementioned Departments.

Photo of Joe McHughJoe McHugh (Donegal North East, Fine Gael)
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Does Senator Moran wish to make a suggestion?

Photo of Mary MoranMary Moran (Labour)
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As the questions I asked on disability were not addressed, I would appreciate it were I able to liaise with someone in that regard.

Photo of Joe McHughJoe McHugh (Donegal North East, Fine Gael)
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Yes, the Senator should revert to the witnesses in respect of any specific questions that were not answered.

Sitting suspended at 12.07 p.m. and resumed at 12.12 p.m.