Frank Feighan (Roscommon-South Leitrim, Fine Gael)
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The health and well-being of all our citizens and the ability to access quality health services on an equal basis is of paramount importance. I genuinely believe this meeting is very significant and represents a valuable opportunity to identify a limited number of feasible opportunities that can help deliver the best possible health outcomes for all people, irrespective of background or means.

The committee met several health service representative organisations on Tuesday informally to help identify a limited number of areas where opportunities exist for greater cross-Border co-operation. It was an insightful and productive meeting, and no doubt it will inform our discussion with the Minister today.

Before the discussion begins I would like members to note that this meeting is confined solely to identifying opportunities to enhance health service provision through North-South co-operation. Specific issues and concerns regarding the health service or individual hospitals in the Republic are not relevant to this meeting, and I ask members to respect this ruling when asking the Minister questions. I invite the Minister to make his statement.

Leo Varadkar (Dublin West, Fine Gael)
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I thank the committee for inviting me here this morning to discuss opportunities to enhance health service provision through North-South co-operation. At the North-South Ministerial Council, NSMC, health and food safety sectoral meeting in Altnagelvin last month, I said that cross-Border co-operation on health was one of the unsung successes of the Good Friday Agreement. There are several very good examples of co-operation in health, such as in radiotherapy services in Derry for all of west Ulster, the paediatric congenital cardiac service for the island, which will be based in Our Lady’s Children's Hospital in Crumlin, health promotion, e-health and food safety. We are an island of just over 6 million people and it makes sense to pool our resources to provide better health care for all our citizens, regardless of politics.

In Ireland, North and South, there is a growing interest in cross-Border all-island health and social care services co-operation where mutual advantage can be demonstrated. That was not always the case in the past, but I am very glad that it is now. That reflected the complexity of health and social care services and the many barriers which may be encountered in attempting to put cross-jurisdictional arrangements in place, including a lack of development funding, different systems for assessing eligibility and a situation in which each jurisdiction is Exchequer-funded only to provide for its own population catchment. There have been several significant cross-Border and all-island initiatives over the past 20 years, with the early experience gained through local and regional pilot projects in the Border area building the confidence to put more permanent collaborative arrangements in place. Today, there are many examples which illustrate that co-operation between North and South in health makes sense. 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 and resources and exchanging good practice. I am committed to strengthening and increasing North-South health co-operation.

North-South co-operation on health matters takes place through the NSMC as well as joint departmental projects. Taking its place within the broad spectrum of public agencies involved in facilitating North-South co-operation is the Co-operation and Working Together, CAWT, partnership, which has played a significant role over the past 20 years in promoting cross-Border health and social care co-operation, particularly in the Border area. CAWT is delivering the health element of the EU initiative for inter-regional co-operation, INTERREG IV, programme, comprising 12 projects with a strong focus on improving access to services, promoting health and well-being, reducing health inequalities and promoting social inclusion. The numbers of patients and clients who have benefited from services is in excess of 53,000 as of March 2015. The new INTERREG V programme has been agreed and I understand a call in the health area will issue in the coming months. There is an increase in the funding available for the new programme, which will continue to deliver tangible benefits to citizens in both jurisdictions.

I will outline some areas of specific co-operation in health. The committee is aware of the development of new radiotherapy facilities at Altnagelvin Hospital in Derry. I recently had the opportunity to see at first hand the progress in the development of the new radiotherapy unit. The previous Minister for Health, Social Services and Public Safety in Northern Ireland, Jim Wells, and I visited the site where construction of the radiotherapy unit started in July of last year. I was impressed and enthused by the dedication of the people I met. This is an exciting cross-Border project that will significantly improve access to radiation oncology services right across the west Ulster region, on both sides of the Border. Among the beneficiaries are people living in County Donegal and surrounding areas. It will provide high-quality services on their doorstep on a par with those provided in the Northern Ireland Cancer Centre in Belfast and in our special centres in Dublin and Galway. The Government has committed capital funding of €19 million towards construction costs, and the HSE will also provide funding for the provision of services to patients per year, of which 385 will be from the Republic. Donegal on its own does not have the population to justify or support a specialist centre for radiotherapy, and nor do Derry, Tyrone and Fermanagh, but taking the four counties together, they have sufficient population and critical mass to justify and safely staff a specialist centre. That is what has been done there. It is a good example of work that could be done in the future in Derry, Dublin and Belfast.

There is continued engagement between the Department of Health here and the Department of Health, Social Services and Public Safety in Northern Ireland on progressing co-operation and finding a solution for paediatric cardiology services on an all-island basis. The expert international working group report on an all-island service for cardiology and cardiac surgery for congenital heart disease was published in October 2014. This report is a pragmatic example of co-operation across both jurisdictions which seeks to create an effective, integrated service for the benefit of patients. It makes clear and explicit recommendations on the development of a single congenital cardiac service for Northern Ireland and the Republic of Ireland. One of the recommendations was that paediatric surgery and interventional cardiology should cease in Belfast and that all services should be provided in Dublin, giving us the critical mass of a population of approximately 6 million, which is needed for such a centre. This development will ensure that a very vulnerable group of sick children and young people get the best level of care no matter where they come from on the island. Other benefits of the service will include an expanded database for research into congenital heart disease and an expanded range of medical services.

A report on north-west cardiology provided to the board of the Saolta hospital group in October 2013 was positively received and its recommendations accepted. The adoption of the recommendations of the report can build and support a robust cross-Border relationship that has the potential to deliver a high-quality service for the benefit of all of the population of the region. In particular, the recommendation to establish a joint cardiology department between Letterkenny and Altnagelvin is very exciting, not solely because of the benefits to service provision for the people of the north-west but also because it will be the first ever joint cross-Border department in medicine or surgery.

The promotion of health and well-being is deemed important for all important for all our citizens. There is important co-operation continuing between the two jurisdictions. There is broad agreement on the need for significant and innovative action to protect the health and well-being of the wider public, and especially children, from alcohol abuse. The two health Departments have co-operated closely here through the work of the North-South alcohol policy advisory group. One such area of co-operation is the introduction of minimum unit pricing. This is an important measure to tackle the harm caused by alcohol in adolescents and problem drinkers. The University of Sheffield reports, which were jointly commissioned by the two Departments, studied the potential impact of minimum unit pricing in both jurisdictions. The two Departments have agreed to work together as far as possible to ensure a co-ordinated approach to minimum unit pricing in terms of timing and rates to ensure health impacts are maximised and the impact on cross-Border trade minimised.

Since the inaugural North-South tobacco conference was held in Belfast in November 2013, which allowed for the sharing of innovative ideas to benefit the health of people from both jurisdictions, there has been significant progress on tobacco control measures. The Public Health (Standardised Packaging of Tobacco) Act 2015 was signed into law by the President on 10 March 2015. This has made Ireland the first country in Europe and the second in the world to pass such legislation. Legislation to introduce standardised packaging of tobacco products has now been enacted in both Ireland and the United Kingdom, and the provisions will come into force in Ireland in May 2016.

Rare diseases have also been discussed at NSMC level. There is broad agreement in principle for future collaboration in this area. The national rare disease plan in Ireland was published in July 2014. The foreword to the plan referred to the policy framework on rare diseases, envisaging a combined approach with EU partners and Northern Ireland to diagnose and treat people with rare diseases.

Dealing with the current high levels of suicide and deliberate self-harm is a priority for the Irish Government. Much has been achieved under our Reach Out suicide prevention strategy and the Protect Life strategy in the North. However, more needs to be done. The development of a range of all-island actions on suicide prevention, together with the long-standing co-operation between the National Office for Suicide Prevention and the Public Health Agency in Northern Ireland, has resulted in several excellent initiatives, including the media monitoring service, the registry of deliberate self-harm, information campaigns and the all-island men’s health forum.

The Department of Health and the National Office for Suicide Prevention are currently finalising a new strategic framework for suicide prevention for the period 2015 to 2020 to follow on from Reach Out. A new suicide prevention strategy is also under development in Northern Ireland. The publication of these two new strategies will present opportunities for further co-operation on suicide prevention initiatives.

The food safety promotion board, safefood, is one of the six North-South bodies established under the Good Friday Agreement in 1999. Members will be familiar with the work of safefood as its representatives attended this committee last month and a detailed discussion took place on North-South co-operation in food safety initiatives to promote healthy eating and combat obesity. safefood is principally charged with tasks involving food safety awareness through public campaigns, conferences, training and advising professionals and the general public. It is also involved in supporting North-South scientific co-operation and links between institutions working in the field of food safety, including laboratories, statutory food safety enforcement agencies and international and domestic research bodies. It has run a number of successful campaigns in recent years. These include the "Operation Transformation" television programme, the Community Food initiative, which aims to promote greater access and availability of healthy and safe food in low-income areas, and eatright.eu, a new website with a focus on healthy eating, food safety and physical activity. safefood's knowledge networks continue to enhance linkages across the island among food safety professionals working in the food production and processing sectors, research and academia and the wider public sectors. Digital engagement is an important feature of campaigns as it allows safefood to engage with customers in a cost-effective manner. safefood can build on this success by continuing to increase public awareness through these channels.

To conclude, some of the best examples of practical public sector cross-Border co-operation are in the fields of health and social care. I acknowledge, therefore, the great work of all those involved in cross-Border health co-operation and the difference they are making to people's lives. The health services in both jurisdictions have evolved in different ways but there has always been enthusiasm about collaboration where it is mutually beneficial. I look forward to continuing and developing this work in the coming years.

Frank Feighan (Roscommon-South Leitrim, Fine Gael)
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I thank the Minister. On behalf of the joint committee, I will ask the Minister a series of questions based on our meetings with health service representative organisations last Tuesday and on other briefings provided to the committee. I thank all the health service representatives for the work they did and for taking time out of their busy schedules for a very informative session last Tuesday.

A number of the representative organisations identified a need for an overarching strategic framework and implementation plan to develop sustainable cross-Border co-operation, as distinct from the existing focus on individual projects. I consider the lack of a framework to be a major stumbling block impeding progress in the implementation of real change on an all-Ireland basis. Is the Minister in favour of liaising with other Cabinet Ministers and his Northern Ireland counterparts with a view to introducing a framework that should lead to a more systematic, co-ordinated approach? As a follow-on point, do the Minister and his officials have regular meetings with their Northern Ireland counterparts in the Department of Health, Social Security and Public Safety with the common goal of enhancing health service provision through North-South co-operation? Is the Minister supportive of the idea of establishing a working group of civil servants from the Department of Health and the Department of Health, Social Security and Public Safety in Northern Ireland to progress the issue in parallel with the North-South Ministerial Council?

The issue of training and accreditation of health professionals in both jurisdictions is very important in the context of the development of services on a cross-Border basis. In particular, there are still significant issues around the recognition of professional qualifications and medical mobility across borders, notwithstanding EU directives in the area. What are the Minister's views on the development of a common register of medical professionals, through liaison with the Irish Medical Council and the UK's General Medical Council, which would end the requirement to register in both jurisdictions? This would significantly reduce costs, including indemnity insurance and professional registration fees, and encourage doctors to operate on both sides of the Border. There appears to be significant scope to extend the GP out-of-hours service in Border areas on a cross-Border basis. I understand that North East Doc has provided cover for south Armagh for some years now and that a similar arrangement is active in east Donegal, where patients can avail of the out-of-hours service in Derry. One significant problem is that GPs here are not entitled to travel to Northern Ireland to see patients and vice versa. Have the Minister or his officials or counterparts in Northern Ireland explored the issue with a view to identifying possible solutions and, if not, will the Minister undertake to do so?

The Minister is aware that alcohol abuse is a serious issue throughout the island. I welcome the comments in the Minister's statement but note that we need an all-island alcohol strategy. Obesity and childhood obesity in particular were referred to by the Minister. Would he consider liaising with his Northern Ireland counterparts on the introduction of all-island measures to combat obesity? Specifically, is the Minister in favour of developing a shared set of public health indicators, as it is difficult to make accurate comparisons in the absence of these indicators? For information, I note that yesterday Colin Regan of the GAA attended the joint committee. The GAA has a Healthy Clubs project. We talk about safefood and getting messages across, and this is absolutely the right vehicle to use, as the GAA encompasses many clubs in rural areas and can address everything from drug awareness to alcohol abuse to community fitness. This could be rolled out not only through the GAA but on a cross-Border basis, and the Minister could also work closely with the IRFU, the FAI and the IFA. We are looking at various bodies, but we are not getting the message across in the way we should. I encourage the Minister to look at the presentation Colin Regan made. He was invited in by Deputy Gerry Adams yesterday and he made a very worthwhile presentation.

On co-operation and cross-Border partnership between the health and social care services in both jurisdictions, there have been a number of successful initiatives in the field of quality and safety training. Are there plans to mainstream successful initiatives to other hospitals as models of best practice? The Minister referred to rare diseases. Deputy Joe McHugh has been instrumental in raising this issue also. Ireland has the lowest ratio of consultant rheumatologists per capitain Europe, with one per 135,000 people. Many patients must travel long distances, particularly from Border areas, to access appropriate treatment. Rheumatology patients in Donegal must travel to Leitrim for treatment since the cessation of rheumatology services at Letterkenny General Hospital. In addition, there is serious concern that expertise is not available nationally for more complex, life-threatening mixed connective tissue diseases including systemic lupus erythematosus and sceleroderma, which are treated primarily by consultant rheumatologists. Does the Minister consider that an all-Ireland centre of excellence based in one hospital would be a viable solution whereby both jurisdictions could piggyback on NHS expertise?

A further issue that has come up is the cost of pharmaceutical drugs in the Republic, which continues to be exorbitant according to international comparisons. While a great deal of work has been done in this area in the last six or seven years, a significant proportion of the overall health budget, at approximately €2 billion, continues to be spent in this area. These drugs can be bought significantly more cheaply in Northern Ireland. While I accept that there are complexities involved, have the Minister or his officials given any thought to an all-island arrangement for purchasing pharmaceutical drugs? Are there at least any lessons that can be learned from Northern Ireland as to how to cut margins? How can the huge disparity North and South of the Border be explained?

Another question that arose with the representative organisations related to the proposal that the planned children's hospital be constructed on an all-island basis. What are the Minister's views? Has the Minister had any discussions with his former or current Northern Ireland counterpart in this regard?

Finally, are his officials looking at organ transplant and retrieval services? How can these be provided on an all-island basis?

There seem to be discussions among medical professionals suggesting it would enhance the service and resolve a number of time factor issues that impact so greatly on organ donation and transplantation. The existing co-operation between both jurisdictions and the UK is testimony to the ability of services to overcome national borders to provide the best possible outcomes for patients.

Leo Varadkar (Dublin West, Fine Gael)
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That is 12 questions. If I speak for four minutes on each, it will be a 48-minute answer, which I do not imagine the Chairman wants.

Frank Feighan (Roscommon-South Leitrim, Fine Gael)
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The Minister should answer the questions as satisfactorily as he can.

Leo Varadkar (Dublin West, Fine Gael)
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I will not be able to answer them comprehensively, obviously, but-----

Frank Feighan (Roscommon-South Leitrim, Fine Gael)
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Maybe the Minister can come back with a detailed statement.

Leo Varadkar (Dublin West, Fine Gael)
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I will do my best. There are many questions and to give comprehensive answers to all of them would take up the rest of the meeting, so I will not do that. The Chairman asked about an overarching strategic framework. The North-South Ministerial Council is designed to do that and has identified areas of specific co-operation, namely, accident and emergency services, planning for major emergencies, high-technology cancer research and health promotion. The bottom-up activity has been most successful - the identification of the need for radiation oncology services in west Ulster, which are now provided in Altnagelvin; the identification by clinicians of the need in respect of paediatric cardiothoracic surgery, which is now happening in Dublin; and deepbrain stimulation, which is now done for many patients from the Republic in Belfast. The area of transplants is also being examined, but is only at the initial stages. The question was whether it would be better to have a top-down approach, rather than a bottom-up approach. I am not sure. Some work was done in 2009 on a strategic framework. The nature of such frameworks is to take forever to be drawn up and then get reduced to the lowest common denominator. I would be interested to hear the views of members on this. If the objective is to deliver cross-Border services in the interests of patients, it could be argued that is best done on a bottom-up approach to respond to service needs as they arise, rather than a top-down approach, but the reverse could also be argued, so I do not have an answer for that one.

Regarding meetings, I meet with my counterpart two to three times a year at ministerial level. I am not sure exactly what happens at Civil Service level. Perhaps Ms Joyce or Ms Hagerty want to answer that.

Ms Miriam Joyce:

Certainly on the acute side, much of it is not face to face meeting, but we have very regular interaction - probably at least on a weekly basis - with our counterparts on various issues, usually projects that are ongoing, such as deep brain stimulation or paediatric cardiology. It is very regular contact, even if not face to face.

Ms Audrey Hagerty:

We liaise quite considerably with CAWT throughout the year on an ongoing basis. As the Minister outlined in his opening statement, there is quite a bit of contact on the issues of tobacco, obesity and alcohol, as well as in the area of suicide with the two organisations responsible for that area of work. There is quite a degree of ongoing co-operation there.

Frank Feighan (Roscommon-South Leitrim, Fine Gael)
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Could the Minister try to arrange to meet with the GAA health club project? It would be worthwhile.

Leo Varadkar (Dublin West, Fine Gael)
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I have done that. I actually launched it. The healthy club project is very encouraging.

On the common register for medical professionals and other professionals, that would be extremely difficult. If we were to have common registration in Ireland and Northern Ireland, all the legislation would first have to be aligned just for doctors, then for nurses, dentists and 14 other professions. About 16 different Acts of Parliament would have to be passed in both jurisdictions. We would have to agree to align our legislation in both jurisdictions and things are different. The universities are set up differently, competence assurance is different, and requirements for continuing professional development are also different. There would also be the issue of extra-judicial decisions. The Medical Council in Dublin hears complaints against doctors and can make serious findings against doctors and then strike them off. If there were to be an all-island medical council that could strike off doctors in two different jurisdictions, I imagine an international treaty would be required. It would need to have the effect of a cross-Border court. That would then apply to the Nursing and Midwifery Board of Ireland, CORU and all the others as well. It is not impossible. Unification of the island might be simpler. That would be the way to start, rather than trying to align 14 different pieces of legislation and create 14 different quasi-judicial bodies with cross-Border powers. We might even need referendums on that. It would not be where I would start in unification. I am not sure how East and West Germany did that, but that would be the case study to look at.

On out-of-hours services, from its commencement to 30 April 2015, 739 patients in Inishowen received GP out-of-hours services in Derry. That is about seven per month. Some 2,839 patients from south Armagh have received GP out-of-hours services in Castleblayney in County Monaghan, that is about 32 per month. Patient uptake in the Inishowen-Derry pilot is quite low. That is partly due to the reduction in the pilot size. Initially, the pilot area was supposed to cover the Buncrana area, but I am told the HSE could not get agreement from the Buncrana GPs, so it did not happen. There is also the issue of accommodation address, which affects people living along the Donegal Border, who are in some cases entitled to NHS treatment because they are frontier workers and use the service in Northern Ireland anyway. The authorities in both jurisdictions have agreed that exploratory discussions should now proceed regarding the potential for extending the service on a trial basis to Blacklion in County Cavan and Pettigo in County Donegal, whereby patients from these areas could avail of an out-of-hours service in Enniskillen, County Fermanagh, or in Omagh, County Tyrone. Initial discussions took place with local GPs, but it was not possible to progress the matter at the time. However, the HSE has now put arrangements in place with Caredoc for the commencement of a new out-of-hours GP service in the Sligo-North Leitrim area later this year. That will allow discussions on the potential extension of cross-Border out-of-hours services in Enniskillen or Omagh to recommence, so they will have another go at that.

On the all-island measures on alcohol and obesity, in respect of alcohol in particular, we try to ensure we implement minimum unit pricing at roughly the same time and rate so that we do not have huge numbers of people crossing the Border to buy alcohol where it is cheaper. That would totally defeat the purpose of doing it. On obesity, we have had discussions but not many. It is important to bear in mind that we are different jurisdictions. We have a plan for alcohol and we are pressing ahead with it. We know what we are going to do this year and enact next year. We will have a plan on obesity this year and we will start implementing it next year. The risk of having an all-island strategy is obvious: everything gets paused, a year or two is spent developing an all-island approach and what inevitably happens is that we have all the stuff we want to do, they have all the stuff they want to do, but all that makes it into the strategy is the crossover, so the sum of the two parts is actually less. If it were a Venn diagram, instead of doing everything within the two circles, we only end up doing the things in the small overlapping section. It would be a great strategy and we could all say it is wonderful and launch it and so on, but would it actually produce better results than us all doing what we want to do anyway? It is probably better that each jurisdiction does what it wants to do on alcohol and obesity and we try to co-ordinate in a practical way, rather than having a lowest common denominator strategy, which would have the problems I mentioned.

The cost of medicines in Ireland is now coming down, largely because of reference-pricing of generic medicines and the various agreements with the Irish Pharmaceutical Healthcare Association on patent medicines. Ireland spends about as much on medicines now as it did ten years ago, which is not the case in most other countries. We came from a very high base, but most countries are still going up, while we have been flat for the best part of ten years. The exception is the very high-tech medicines, which happen to be very expensive. They are only made by one manufacturer, which generally has us over a barrel when it comes to pricing. Members will have seen that with Soliris and some other medicines in the last few months. In theory, medicines could be procured on an all-island basis. That would make them cheaper here but more expensive in the North. I am not sure the North would be up for that.

The best option for us would be for the Republic of Ireland to buy into the NHS purchase system to enjoy the economy of scale of a population of approximately 60 million between Britain and Ireland. One could get a much better price with that kind of buying power but why on earth would the pharmaceutical industry want to do that? We cannot force the industry to agree to purchasing across two countries. Perhaps we would need to unify Britain and Ireland before we could do it because we cannot force somebody to make an agreement. It suits the pharmaceutical industry to have different agreements with different countries and, often, to pick off the smaller ones with the highest prices, with a view to setting a benchmark price for those with the buying power. We are, however, starting to procure certain very expensive medicines on a Europe-wide basis. A European directive has been introduced which specifically permits us to do that. For example, as vaccines are more or less the same and used similarly in every country, procuring them with a buying power of 500 million people is obviously much better than a buying power of 5 million or 60 million people. A similar approach may be adopted in respect of hepatitis C medicines, which we would purchase with the buying power of 27 countries rather than the alternatives of one country and a province or two countries.

The children's hospital project began before I came into office. I am not sure whether Ms Miriam Joyce wants to comment on that project. The children's hospital is designed for the Republic of Ireland rather than for all of Ireland. A major children's hospital would still be needed in Belfast given its catchment population of 1.5 million. We would like to provide some of the high level specialist services for all of Ireland in the new hospital. Paediatric heart surgery is already agreed and I think we could also provide other services, such as transplants. That has to work three ways, however, because in some cases services will be provided out of Belfast or Dublin for all of Ireland, out of Derry for all of west Ulster and, where we do not have the population for certain very rare procedures, it makes sense not to provide them in Ireland at all. They would instead be provided out of Birmingham, Newcastle or Great Ormond Street in London. There are, therefore, two dimensions of co-operation, namely, east-west and North-South.

Joe O'Reilly (Cavan-Monaghan, Fine Gael)
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I welcome the Minister and thank the Chairman for arranging these practical sessions. I welcome the confirmation by the Minister that solid moves are afoot on minimum unit pricing of alcohol in the Republic and co-ordination with Northern Ireland on the matter. That will be an important achievement for obvious reasons. As a representative of Cavan-Monaghan, it is critical that there is co-ordination on any new measure that is introduced because the alternative will be a major exodus to purchase alcohol. There is good co-operation on tobacco products, in which regard the recent initiatives in the Republic are to be commended.

I recently attended a briefing session with HSE officials in our region. Oireachtas Members and the officials referred to obstacles in providing good dental and orthodontic services arising from the difficulties in recruiting dentists. Does the Minister see potential in reducing dental waiting lists through North-South actions? He will be acutely aware this is happening on an informal basis in that people are travelling to Northern Ireland for orthodontic treatment.

I was proud to take part in the recent discussion in the Dáil on cochlear implants given their significance for so many people. Does the Minister see potential in North-South co-operation in hearing and specialist services? I was glad to hear him note that we will have specialist paediatrics services. I welcome the congenital cardiac abnormalities initiative. He correctly pointed out that while we cannot provide a physical building to house services for children in all of Ireland, we can provide specialist services in Belfast and Dublin.

I take his point that it would be easier to unite Ireland than to codify and bring together all the legislation and professional bodies to achieve harmonisation of qualifications. What initiatives might be taken to enhance staff mobility between North and South? Could that be done without complex legislative reforms?

Brendan Smith (Cavan-Monaghan, Fianna Fail)
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I thank the Minister for his comprehensive presentation. I noted to the representative groups at our meeting with them on Tuesday that we have enjoyed good co-operation over the years. It is more the fault of the political system than the people who deliver health services that such co-operation has not received the attention it deserves. I am a firm believer in responding to service needs rather than devising grand strategies. We are all familiar with the territorial nature of agencies, whether on a national or local basis. It is important to respond to service needs in a practical way, with people on the ground who can take initiatives and work with their colleagues in the adjoining jurisdiction. Ear, nose and throat and urology services for my constituency of Cavan-Monaghan were delivered from Omagh hospital, and there has been good co-operation across the Border. We should consider ways of expanding existing services. I would also like to see progress on improving doctor on call services to the central Border region of Cavan-Fermanagh and Monaghan-Fermanagh. There has been good co-operation in respect of ambulance services, although I do not know whether this is on a structured basis. I presume that we could also make improvements to providing ambulance services on a North-South basis, particularly in respect of the Border area.

Deputy O'Reilly referred to our discussion with the HSE last Friday regarding the huge cost that families face for orthodontic services. Many families purchase services north of the Border. The National Treatment Purchase Fund previously purchased ophthalmology and cataract services from a private hospital in Derry to reduce the waiting list for these services in the Cavan-Monaghan area. Orthodontic services and the dental service for school children are under huge pressure. If there was scope to buy in services on a one-off basis it would be beneficial in terms of reducing the current backlog. This is an area in which we would like to see progress.

I will conclude by asking about the development of new facilities. I believe that when substantial new facilities are being planned or provided in the Northern jurisdiction or in our own State, provision should be made on an all-Ireland basis, particularly in regard to specialties. We are fighting to retain hospital services in our own localities if we can. Many people would willingly go to any part of Ireland to avail of a specialist service in many areas and ensure the necessary intervention is provided when needed. We need to be developing services in many specialist areas on an all-Ireland basis. I hope provision can be made for specialist areas in the national children's hospital. The South West Acute Hospital in Enniskillen was the last major new health service provision to be made North of the Border. To my knowledge, some of that hospital is not being used at present. It is a shame if that is the case. I am sure there are some areas and services which are needed both North and South that could be provided there. We have to look at the development of services, particularly in that respect. As the Minister quite rightly pointed out, Ireland is an island of 6 million people. We cannot have specialist services everywhere. We must try to ensure there is the utmost co-operation. I strongly believe the best improvement we can make in the provision of additional services should involve responding to service needs and driving initiatives at local level, rather than waiting for grand strategies to be drawn up North or South of the Border and finally agreed. I am very conscious that nobody wants to cede territory to some extent.

Peter Fitzpatrick (Louth, Fine Gael)
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I thank the Minister, Deputy Varadkar, for his presentation. As he knows, I come from County Louth, which is a Border county that has a close relationship with Newry. It is a 15-minute drive from Dundalk to Newry. The Minister spoke earlier about the difference in the price of prescribed drugs between the North and the South. My constituents contact me on a regular enough basis about this issue. They are concerned because vast price differences leave them with no option other than to travel to the North to purchase drugs. They have noticed lately that pharmacies based in Newry are now advertising in the South of Ireland.

I know this matter has been examined by the Joint Committee on Health and Children. Would it be possible for this committee to consider whether it has an opportunity to work with pharmacies from both North and South? Perhaps we can pool our resources together to reduce the cost of drugs. As the Minister knows, we have come out of a recession. I have always said I firmly believe that one's health is one's wealth in life. One can have lots of money in the bank, but that does not matter if one does not have one's health. As the Chairman said, the Government has done a fantastic job over the last four or five years in reducing the cost of prescription drugs. It is an awful shame that people from my local area have to cross the Border and that people from the far side of the Border have to come to our area to advertise their drugs at a cheap price.

The Minister knows that I am the Joint Committee on Health and Children's rapporteur on the issue of obesity, which we have discussed on many occasions. I would welcome an opportunity for the North and the South to work closely together to try to combat the current epidemic, which is very serious for children and adults. At a time when we are trying to cut back on costs, we should reflect on the link between obesity and heart problems and diabetes, etc. Obesity has an impact on every organ of one's body. Is there anything we can do to help the Northern side in that regard?

Leo Varadkar (Dublin West, Fine Gael)
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I will have to come back to the committee on the questions of orthodontics, oral surgery and oronasal surgery. I just do not have enough detail on those matters to hand. In orthodontics, it is intended to do some outsourcing to the private sector towards the end of the year to try to reduce the waiting lists, particularly for surgery. Some of that is done in the Beacon Hospital already. There will be more towards the end of the year. That is already in the service plan.

I often hear of patients who go to the North on their own bat and then claim it back on the cross-Border directive. We are probably going to see a lot more of that in the years to come. Many more people will take advantage of the cross-Border directive to avail of treatments in another country, which then get billed back to their home country. I think that is probably a good thing. If significant numbers of people are going overseas to buy treatment they should be getting here, it might be easier for the Minister for Health to get the money in the first place. If people are going off to get treated in England or the North instead, it might be a game-changer in the medium term.

Deputy O'Reilly will be aware that the bilateral cochlear implant programme started quite recently under Dr. Laura Viani in Beaumont Hospital and Temple Street Children's University Hospital. The real success of that programme will be shown quite soon in an RTE documentary. It is powering away through the waiting list. I am not sure whether it is yet in a position to take patients from North of the Border. I do now know where they are done in the North. It is certainly worthy of consideration.

There is a certain amount of staff mobility already. Cardiothoracic surgeons come to Dublin from Belfast to operate on children. Deputy Smith will be aware that when we were short on transplant surgeons in Beaumont Hospital for a while, we got a dig-out from the surgeons from Belfast who came down and did some transplants here. There is some mobility. There was a coaching and mentoring element to one of the INTERREG programmes, which was a workforce mobility programme, to facilitate the development of leadership skills and the sharing of knowledge across the Border. There was also a social worker leadership aspect to enhance the leadership skills of social work team leaders. The project is also delivering on the moving and handling training passport on a cross-Border basis so that people can have one that applies across the Border.

Under EU directives, it is generally not all that hard for someone who qualified in the EU to get recognised in another country. One does have to pay the relevant fee, however. It occurs to me that if somebody is registered already in the Republic of Ireland, we should waive the fee for them to be registered in the North, or vice versa. It is just a thought and I am not promising anything. We might find we cannot do that without extending it to everyone in the European Economic Area, on the basis that we cannot treat any European citizen any more favourably than another. Maybe it is an idea.

I was invited by Jim Wells to visit the new hospital in Enniskillen. I am told it is very impressive. It is one of the most modern hospitals in Ireland or Britain at this stage. It is also very big, for whatever reason. I am not sure whether the relevant authorities were thinking ahead to cross-Border reconfiguring. I do not know whether they are planning to treat people from Sligo, Cavan or Monaghan in Enniskillen. I intend to take a look at the hospital in the next couple of months.

The HSE does have a tender out at the moment to outsource many of those who have been waiting more than a year for inpatient procedures, outpatient procedures and outpatient appointments. I do not know whether any tenders came in from any of the trusts North of the Border. I would be surprised if they did not.

Martin Ferris (Kerry North-West Limerick, Sinn Fein)
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I thank the Minister for his presentation and his detailed response to the 12 questions that were put to him by the Cathaoirleach. It is regrettable that a Northern Minister is not here, or even that a unit representation is not here. This is an ongoing thing. It is for our mutual benefit, including the benefit of our constituents, that we are seeking to take advantage of any type of co-operation that is necessary. Unfortunately, not everyone is represented.

I welcome the extent of North-South co-operation in a number of areas, as outlined by the Minister. It is to be welcomed and supported. I hope it will continue and expand. The Minister spoke about the price of medicine and drugs and the problems in dealing with that. He mentioned a €500 million EU structure that offers some possibilities for the future. It is something that all of us would like to see. The cost of medicine and drugs is quite crippling for many people, especially those who do not have medical cards.

I welcome the co-operation with regard to alcohol abuse, which is ingrained in our society.

From a sporting perspective, for example, I doubt that there are many clubs that do not receive sponsorship or support from local pubs and so forth. They have no other choice, as the situation has changed so much in the past 25 or 30 years such that football, soccer, hurling and boxing clubs, for example, have a dependency on publicans and the like for support. Perhaps some State funding for clubs, in conjunction with funding for the national sports bodies, should be considered.

Regarding below-cost selling, I do not believe minimum pricing will resolve the issue. What is required is a form of excise duty on products which could then be used to fund programmes of education and so forth to help to address the problem, particularly as it relates to alcoholism which is ingrained in our society. Perhaps the Minister might respond to this suggestion.

One of the most disturbing aspects is suicide and the lack of suicide prevention measures. It is ravaging communities, North and South. On Monday night I attended the funeral of a 29 year old constituent who had taken his own life, having been released from a psychiatric ward the previous day. Before coming to Dublin on Tuesday, I attended the funeral of an 83 year old who had taken his own life. These give an indication of the size of the problem. Every month I attend the funeral of someone who has taken his or her own life. It is a major problem, much of which is down to the way we treat our fellow human beings and how some people grow up with a sense of inequality and hopelessness. I was involved with a number of local projects that dealt with this issue, particularly as it affected young people. On reflection, though, we approached it in the wrong way. There was a glorification of the person who had taken his or her life. Young people said on Facebook that he or she was a lovely person and so forth. That was counterproductive. We need an all-island strategy to deal with the issue. It will probably be done through education programmes in schools and by making facilities available for those who are suffering from depression. If one drives down the Falls Road in Belfast, one will see public offices that were there to help people who were suffering from depression and had suicidal tendencies. We must do something, as this is one of the most pressing issues facing young people in particular, but they are not the only ones affected. Once, it was practically unheard of for a young woman to take this option. Will the Minister respond to this point?

I thank the Minister for his presentation. We should utilise our abilities in an all-island context. This is a small island with 6 million people and the same issues affect everyone across it. Putting services in place in a co-operative way - from the point of view of price and in terms of having proper state-of-the-art facilities available - makes common sense and should be pursued and I hope it will be.

Mary Moran (Labour)
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I welcome the Minister, Deputy Leo Varadkar, and thank him for his presentation. I wish to raise a few points. Nearly all of us present live in the Border area and have similar interests; therefore, the same issues are arising. However, one cannot overemphasise the need for services. I live in Dundalk and there has always been a good link-up between it and Newry in the provision of maternity services.

I have raised a matter with the Minister previously, namely, the provision of psychological services, particularly for children with intellectual disabilities. As I say constantly, there is no child psychiatrist in County Louth for children with an intellectual disability. It is heartbreaking to see the number of people who are trying to access services. There is a correlation between the North and the South in some regards, but could something be done to deal with this matter? I raised it yesterday. Recently, there have been improvements and we have been told that jobs are being advertised, but they are actually being readvertised because the HSE cannot find anyone. It states this is not because of salary issues, but if child psychiatrists can be hired in the North, I do not know why we cannot find them just across the Border. Is there an initiative or a plan in place or could the Minister discuss this matter? People swap. Within disability services there are quite a number of occupational therapists and physiotherapists who live just across the Border. The overall issue is a major concern for me.

Regarding drugs and prescriptions, one must consider the matter from both sides. As Deputy Peter Fitzpatrick stated, people will travel to the North for their medicines, but they will also travel to the North for outpatient treatment, for example, at Daisy Hill Hospital. As there are shorter waiting times, they travel to the North instead of heading 20 miles south to Our Lady of Lourdes Hospital, Drogheda.

If we can have co-operation between the North and the South, I urge the Minister to consider the matter of disability services specifically. There is a major shortage, chiefly of psychiatrists for children with disabilities but also of psychologists, speech and language therapists, occupational therapists and physiotherapists, and the waiting lists are long.

Frank Feighan (Roscommon-South Leitrim, Fine Gael)
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On behalf of the joint committee, I congratulate Mr. Brady on his recent election as an MP and wish him every success. We are delighted to have him here.

Mr. Mickey Brady:

Go raibh maith agat, a Chathaoirligh. I thank the Minister for his presentation.

I have sat on the health committee at Stormont for approximately seven and a half years. One of our main issues is health inequality, as illustrated in the Chief Medical Officer's report three years ago. It highlighted how, if one boarded a bus in central Belfast and travelled to Finaghy in the leafy suburbs, one would live nine years longer due to the lifestyles people were forced into having by deprivation, etc. I am unsure whether there is an urgent need to address anything like this in the South as there is in the North.

I agree with Deputy Martin Ferris in that it is regrettable that the Minister's counterpart in the North is not present and that there is no Unionist representative in attendance. It is important that this section of our community be represented.

The Minister mentioned out-of-hours services, particularly in south Armagh which forms part of my constituency. There are many examples of good co-operation, for example, the renal unit at Daisy Hill Hospital where six beds are reserved for people from north County Louth. This has made a major difference to users of dialysis services in that they do not need to travel to and spend the whole day in Dublin. They can go to Daisy Hill Hospital and be home by lunchtime, which is important in terms of the quality of life of those who must undergo this treatment.

According to figures made available two years ago, approximately 35,000 patients passed through Daisy Hill Hospital's emergency department.

Approximately 3,500 were from the South and the numbers are increasing. There are some very good examples such as CAWT, Co-operation and Working Together, with which I have had some dealings during the years. It provides a very good cross-Border and all-Ireland service. Incidentally, I have been to the hospital in Enniskillen which is state of the art. I am sure the former health Minister, Mr. Jim Wells, had a united Ireland in mind when it was commissioned, but I will not get too caught up in that aspect of the matter.

In terms of GAA healthy club projects, three of the Border counties come under the auspices of the Ulster Council which is based in Armagh. It is perhaps incumbent on the Minister to speak to his counterpart in the North about co-operation with the GAA clubs involved in the Border counties. It may be difficult because of the jurisdictional aspects for people from County Monaghan, for instance, to attend meetings in Armagh; it may not be feasible for them to do so and, apparently Mr. Tom Elliott, MP, MLA, is taking his seat at Westminster. He has refused and continues to refuse to have any dealings with the GAA. These are barriers that have to be overcome and it is incumbent on all of us, including the Minister, to raise the issue with the Minister for Health, Social Services and Public Safety, Mr. Simon Hamilton, MLA.

Frank Feighan (Roscommon-South Leitrim, Fine Gael)
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I thank Mr. Brady.

Maureen O'Sullivan (Dublin Central, Independent)
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The presentations on Tuesday were very interesting and we certainly got from them good examples of best practice in seeking co-operation between the North and the South. However, the point made about the need for strategic direction and strong leadership was made forcefully. The impression I got from the Minister was that he was discussing the practicalities of that co-operation and saying all-Ireland co-operation was not feasible in quite a number of areas because of the practicalities mentioned.

The Minister said there was an agreement on minimum pricing of alcohol. When does he expect to see progress being made on that matter to enable it to become a reality? Is there agreement in the two alcohol policies on anything else? As there is a new national drug strategy in motion, does the Minister envisage cross-Border co-operation or discussion on how we could co-operate in terms of the national drugs strategy.

One point that really struck me in one of the presentations on Tuesday concerned the exchange of data, in particular figures for inequality and health outcomes and life expectancy for persons who lived in poorer areas. I see a role for a greater working together on such data which could direct policy.

Co-operation and Working Together applies to Border counties. Does the Minister envisage it being extended on an all-Ireland basis, as a way to move certain practices forward?

I receive a lot of calls, as does everyone else, about hip and knee replacement operations in particular. Are there plans for further cross-Border co-operation on this issue under the cross-Border directive governing the purchase of treatment abroad?

My last question relates to rare disease, a matter which the Minister has mentioned. There are children who suffer from a rare disease in Donegal. For some of them the disease is terminal. With the pathways being developed, does the Minister see a way for these children to access services in Derry or Belfast? This would be of considerable benefit to their well-being and that of their families.

Frank Feighan (Roscommon-South Leitrim, Fine Gael)
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I thank the Deputy.

Seán Crowe (Dublin South West, Sinn Fein)
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I apologise for being late. My excuse is that I was in the hospital system.

On previous occasions the two Ministers would have attended the committee - for instance, the former Minister for Education and Skills, Deputy Ruairí Quinn, and the Minister for Education, Mr. John O'Dowd, MLA. It was useful that they spoke jointly about the co-operation enjoyed but also about the difficulties and the barriers encountered. Will the Minister expand on some of the road blocks or difficulties experienced? Are they political? How many of them are practical?

Previous speakers at this committee spoke about raising the quality of some services, for instance, children not having to travel to Britain. They should just have to take a short drive down the road rather than having to catch a flight and stay in hotels.

I do not know if the Minister mentioned the national children's hospital. I could raise the issue of its location, with which I had difficulties. People want to know what is happening. Those involved in the children's section in Tallaght hospital are concerned about beds that have mysteriously been disappearing out of the system. On the hospital, does the Minister see it providing services on an all-Ireland basis? If he does, when will this kick in? From a practical perspective, when will children see the benefits?

Recently,there was controversy surrounding the cost to the health service in this jurisdiction of treating a number of people who suffered from a rare disease. Did the Minister have practical discussions with his counterparts, not only in the North but also in Britain, about coming together, not only across these jurisdictions but also on a European-wide basis, to look at the cost factors? Recently we had discussions on the spending power of multinationals and how they could bring down prices and so on. Have there been similar discussions, not only with the Minister's counterparts in the North but also across Europe on the issue?

What are the practical things the Minister believes the committee can do? As he is probably aware, it has been doing a lot of work to reach out to many of the Unionist and Nationalist areas in the North. Does he see any benefit in us looking at or visiting some of the hospital or medical settings to see what is and is not working? In practical terms, we want to come back with information on best practice, what works and what does not. Would this be of any benefit to the work done in the Minister's Department?

Frank Feighan (Roscommon-South Leitrim, Fine Gael)
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I thank the Deputy.

Leo Varadkar (Dublin West, Fine Gael)
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On the issue of alcohol abuse, I do not want to get into the arguments about sport sponsorship. They have been well rehearsed in other committees and the public domain and the committee knows where we are going on the issue. We will not ban sponsorship outright, but we will regulate and restrict it and ensure the regulations in law can be enforced because, to be frank, the current codes of conduct are being widely flouted.

The difference between introducing minimum unit pricing and increasing excise duty has been looked at a few times. The problem we have with cheap alcohol is that it might represent below cost selling. We do not know if it is or not because no one knows what the cost is for sure. Some multiples are selling alcohol very cheaply in order to drive footfall. They do not make a profit but make it on the other things people buy when they go into a store. The problem with increasing excise duty is that the multiples could still sell alcohol at a price that is lower the rate of excise duty. For instance, there could be excise duty of €2 on every can of beer, but the multiples could still sell it for €1.50, take the hit and make a profit elsewhere. Minimum unit pricing does not allow this practice. It sets a floor price based on the number of units of alcohol in a product. No matter what the rate of VAT, excise or anything else is, it is the minimum price and it will be an offence to sell it any cheaper. That is why the research indicates it would be more effective than increasing excise duty. That was the finding of the common research carried out in Sheffield which had been commissioned by the two Departments, North and South.

While this is not to say excise duties might not increase, we are convinced that minimum pricing would be the most effective measure.

At the NSMC meeting before last, Ms Michelle O'Neill, MP, MLA, proposed a joint North-South strategy on suicide and we examined it seriously. There are a few difficulties, including the fact that our new strategy is ready and will be published during the next few weeks by the Minister of State, Deputy Kathleen Lynch, and we did not want to go back to square one and develop a new strategy. We also found many difference in implementation structures, the availability of services and the way schools and hospitals work. We have a National Office for Suicide Prevention, whereas in the North it is managed through the Public Health Agency. There were too many difference to make it practical. Although we could have put something together, it would have been wishy-washy. We wanted a specific strategy with specific actions and a named person who was going to do them, and we could not do it across the two jurisdictions. We did agree to co-operate in areas where it made sense, for example research, evaluation of the effectiveness of policies, awareness campaigns which could be similar on both sides of the Border and sharing and learning good practice. While there will be a North-South dimension to the new strategy, it will not be a single strategy.

I will look into the issue of the child psychologist in County Louth. I am not sure whether the issue is lack of funding for the post or that they cannot recruit.

Mary Moran (Labour)
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They cannot recruit.

Leo Varadkar (Dublin West, Fine Gael)
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If the post cannot be filled, perhaps we could examine doing something in the North if there is capacity there. I add my congratulations to Mr. Mickey Brady, MP, MLA, on his recent election to Parliament. All statistics show an association between low income and ill health which is very much linked to lifestyle including higher rates of smoking, alcohol consumption and obesity and much lower levels of physical activity. While some take the view that low incomes make people smoke and drink more and go running less, it is controversial and others argue that these social determinants of ill health are multifactorial and are due to a number of factors including genetics, parental upbringing and the environment in which people grew up. In some cases, they are explained by personality, and one can see major differences in health in the same family between people who were brought up in the same place by the same parents. I do not subscribe to the view that correcting economic inequality will automatically improve public health. While I accept that there is correlation between ill health and low income, the reasons are indirect and complex.

Regarding the new drugs strategy, I do not know if there are plans to do anything on an all-island basis and I will discuss it with the Minister of State, Deputy Ó Ríordáin, in the coming weeks and see if there is anything that would make sense in the area. The same issues would apply as to other all-island strategies.

I have not had a chance to meet Mr. Simon Hamilton, MP, MLA, in his new role. I met him when I was 18 or 19 when we were almost on the same Washington-Ireland programme. I would be interested to meet him. It is an interesting move from finance to health. I have not seen a finance minister become a health minister before. It is new precedent and it will be interesting to see how somebody whose job it was not to give out any money will be in a job where he will be hungry for money. I wish him the best and look forward to meeting him, which I hope to do in two weeks’ time at the NSMC in Dublin and have a side meeting with him there.

There is probably not much of a case for cross-Border co-operation in hip and knee surgery. Hips and knees are relatively straightforward, can be done in relatively small hospitals and do not require a critical mass or a very high level of specialisation. The solution to making them happen is probably to increase the capacity in Cappagh National Orthopaedic Hospital and outsource to the private hospitals in Dublin, which we intend to do, rather than sending people to Enniskillen or Belfast. It is intended that anybody who has been waiting more than a year for a hip or knee operation will have it done by the end of the year. It will be done through outsourcing, by and large. One finds that although people say they have been on a waiting list for two or three years, when one checks the facts one finds that they are not.

I met some of the families from Donegal whose children have rare diseases. Some of these diseases are not very rare, for example, while cystic fibrosis is technically a rare disease, it is not very rare. The same goes for haemochromatosis and a few others. Given that the diseases are all different, although many people are affected, they are all very different and cannot all be seen by one specialist in one specialist centre. This is well understood. There is a case for people from Donegal to attend in Derry or Belfast if the services are available and if they so wish, given that the journey from Donegal to Dublin this extremely long. In some cases, the HSE pays for travel costs from Donegal, including flights in some cases, which is very expensive. There is room for co-operation there.

The planning application for the national children's hospital will be made in the next few weeks, at long last. The planning application will include the satellite centres in Blanchardstown and Tallaght, which will be located at the fronts of the two existing hospitals. Assuming, not supposing, An Bord Pleanála, grants permission, which usually takes approximately six months, we hope to have full planning permission by December or January, begin site works immediately and have the satellite centres and hospital well under construction by this time next year. We hope to open the satellite centres in Tallaght an Blanchardstown first in 2017, which is not very far away, and the hospital on the main campus open in 2019 and fully commissioned by 2020. It will happen, if we stick to the plan. If we do not stick to the plan but return to the old debates about tri-location, co-location and where it should be located, we will be back to square one and I do not know how Temple Street or Crumlin will last. It is intended that while there will not be inpatient beds at Tallaght or Blanchardstown, there will be 23-hour observation. This means wards not currently used in Tallaght could be used for adult patients, however none of it has been planned out or thought through fully. Tallaght needs additional capacity.

While it will be a national children's hospital, not every child in Ireland will have to go there. There will still be excellent paediatric services in Cork, Galway and many other hospitals. It will be a secondary hospital for the greater Dublin area and the only people who will attend from outside this area will be those who need to see a particular type of specialist. Some of the specialties could be done on all-island basis. Compared to the hundreds of thousands of children who will attend every year, the numbers who will need to travel from other parts of the country will be relatively small.

Frank Feighan (Roscommon-South Leitrim, Fine Gael)
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I thank the Minister for meeting us today.

Brendan Smith (Cavan-Monaghan, Fianna Fail)
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Deputy Kitt sends his apologies for his absence, as he had to chair the Dáil. He wanted to make a point and perhaps the Minister would reply to him in writing. The people of north west Donegal are sourcing some cancer and stroke services at University College Hospital Galway and there are particular pressures there. I presume the developments at Altnagelvin Area Hospital will provide some of the services that are sourced in Galway. Is there a plan on a North-South or east-west basis to provide additional stroke services for the people in the north west and down as far as Galway?

Leo Varadkar (Dublin West, Fine Gael)
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Although I am not aware of any plans about stroke services, I can check it out and reply to the Deputy.

Seán Crowe (Dublin South West, Sinn Fein)
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My colleague raised the cross-Border issue and the GAA.

Leo Varadkar (Dublin West, Fine Gael)
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I did not quite follow what the Deputy said.

Seán Crowe (Dublin South West, Sinn Fein)
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There was a meeting yesterday with the group involved. There are a number of teams, the majority of which are in the North. It is a cross-Border process. There is connectivity between areas such as mental health, alcohol-----

Leo Varadkar (Dublin West, Fine Gael)
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Is this-----

Frank Feighan (Roscommon-South Leitrim, Fine Gael)
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We have raised the matter and the Minister is aware of it. Is that okay?

Seán Crowe (Dublin South West, Sinn Fein)
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Yes.

Frank Feighan (Roscommon-South Leitrim, Fine Gael)
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I thank the Minister for engaging in what has been a constructive and informative discussion. We look forward to receiving some replies, although the Minister has answered most of the questions asked. We wish him every success both now and in the future. I also thank the officials for all of the work they have done.