Cormac Devlin (Dún Laoghaire, Fianna Fail)
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On behalf of the committee, I extend a warm welcome to Professor Deirdre Heenan from Ulster University and Professor Anne Matthews from Dublin City University. You are both very welcome and are not strangers to the Houses. I know you have been here before, but it is a pleasure to have you here at this committee. The format of the meeting is that I will invite Professor Heenan and Professor Matthews to make opening statements. These will be followed by questions from members of the committee. Each member has seven minutes to ask questions and for witnesses to respond within those seven minutes.

Before I begin, I wish to remind members of the constitutional requirement that in order to participate in public meetings, members must be physically present within the confines of Leinster House complex. Members of the committee attending remotely must do so from within the precincts of Leinster House. This is due to the constitutional requirement that in order to participate in public meetings, members must be physically present within the confines of the place where Parliament has chosen to sit. In that regard, I would ask members partaking via MS Teams that prior to making their contributions to the meeting, they confirm that they are on the grounds of the Leinster House complex.

Members and witnesses are reminded of the long-standing parliamentary practice that they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable or otherwise engage in speech that might be regarded as damaging to the good name of the person or entity Therefore, if their statements are potentially defamatory in relation to an identifiable person or entity, I will direct them to discontinue your remarks and it is imperative that they comply with any such direction. As the witnesses will probably be aware, the committee will publish the opening statement on its website following this meeting. MPs participating in the committee's session from a jurisdiction outside of the State are advised that they should do so, but be mindful of their domestic laws and how it may apply to their participation in proceedings.

I now invite Professor Heenan to make her opening statement.

Professor Deirdre Heenan:

I thank the committee for the invitation. Providing healthcare services commands one of the largest allocations of public funding on both sides of the Irish Border and concerns over the efficiency and effectiveness of these systems are perennial.

Health is already an established area of North-South co-operation. The North-South Ministerial Council, NSMC, established under strand two of the 1998 Good Friday Agreement, brings together the two Governments on the island of Ireland to develop consultation, co-operation and action within the island of Ireland and health is one of the six agreed areas of cooperation. Despite this, cross-Border health is a woefully underdeveloped area of public policy and there appears to be little appetite to address this by the Administrations on either side of the Border. Aside from the notable exceptions of the congenital heart disease network and the North West Cancer Centre at Altnagelvin, which were developed over a decade ago, there has been relatively little activity in this key policy area. Following these much-lauded initiatives, the approach to date has been minimalist and often project specific.

When compared to other European countries, both jurisdictions have relatively poor population health outcomes. The main causes of premature deaths are the same, namely, cardiovascular disease, cancer, accidents and suicide. Notwithstanding the differences in structure and funding mechanisms, the two healthcare systems suffer from similar problems in the form of lengthy waiting lists, staff shortages, a lack of focus on prevention and resources spread thinly across too many hospitals.

Given the dominance of healthcare issues in the politics of Ireland, North and South, the lack of knowledge and research is extraordinary. While this may be partly explained by the political sensitivities of all-island working, it does not explain why the potential benefits and barriers have not attracted substantial political and policy attention. Major policy reviews on both sides of the border have paid scant regard to the potential of cross-Border working.

The limited existing research identifies a number of key barriers to collaboration including a lack of leadership, difficulties in comparing data and limited opportunities to share knowledge. It also identified a range of potential benefits to be gained from increased collaboration in healthcare. Key acute healthcare services, including cystic fibrosis, ear nose and throat surgery, orthopaedic surgery, treatment of rare diseases, cancer care and acute mental health services, were identified as possible areas of focus.

Additionally, the South West Acute Hospital, SWAH, in Enniskillen presents substantial opportunities for innovation in respect of service provision on a cross-Border basis. This work concluded that working together to address major health issues has the potential to deliver significant additional gains for the population of each jurisdiction that could not be achieved by each system working in isolation. Frequently, co-operation and collaboration are used interchangeably by politicians but in policy terms they mean very different things. Co-operation is where the respective jurisdictions act independently to achieve a parallel and mutually beneficial outcome. An example of co-ordination is the development of the M1-A1 dual carriageway. Collaboration is where the individual jurisdictions work together and combine their resources in a particular initiative with a common goal in view, including working sufficiently closely to manage risks, achieve economies of scale, overcome obstacles and eliminate administrative duplication. An example of collaboration in this context is the North West Cancer Centre.

All-island approaches have the potential to address some of the current issues and ensure Ireland as a whole is well placed to deal with future challenges. However, without a framework and a vision for collaboration, interventions will remain fragmented and piecemeal. Robust mechanisms and policies are needed to tackle systemic and complex healthcare challenges, assess potential economies of scale and support the work of clinical staff with scarce specialist skills. Given the similar health challenges faced by each jurisdiction, working collaboratively in order to maximise the potential for service planning and delivery should be a policy priority.

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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I thank Professor Heenan. I now call Professor Matthews to make her opening statement.

Professor Anne Matthews:

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

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

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

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

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

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

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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I thank both witnesses for their opening statements. We will now turn to questions. The first speaker is Ms Pat Cullen, whom I understand is online.

Ms Pat Cullen:

I thank the Chair. Good morning to Professors Heenan and Matthews. I thank them for both their submissions, which I found very interesting reads.

Recently, we in Sinn Féin were involved in and produced a discussion paper. If the committee and witnesses have not had an opportunity to read it, I would certainly be happy to share it with them. It sets out the case for an all-Ireland healthcare service. In that territory, we make reference to Professor Heenan's paper on cross-Border co-operation health in Ireland. I remember having conversations with her about that paper when I was the director in the college here in Belfast. In her paper, she rightly says:

The reality of the waiting lists in the north mean those who require elective care either pay for it or languish for years on a waiting list. The dreaded two-tier healthcare system has arrived by stealth. Unionists can no longer be assured that the NHS is viewed as an immutable asset.

Recent research by the ESRI has indicated the North and South have followed the same trajectories for outpatient waiting times. However, the North has a much higher percentage of people waiting in excess of 52 weeks. In addition, the ESRI found that, on average, people in the South could expect to live approximately 1.5 years longer than their counterparts in the North and people in the North live two years less than their counterparts throughout Britain.

We also know from the work of Mr. Ben Collins and others, which has been produced more recently, that healthcare staff are paid much more in the South than in the North, which has always been a bone of contention with ourselves in the college, and that this is a particular challenge along the Border areas. We know Mr. Peter Donaghy's work that deaths from cancer in the North are now 24% higher than those in the South. Our clinicians are constantly asking for more collaboration between the North and South, for example, people like Professor Mark Lawler from Queens University.

A small island with around 7 million people cannot continue to operate two separate healthcare systems. Duplication does not make sense and both witnesses have said that on many occasions. We have many more examples of where collaboration could work over and beyond the two Professor Heenan has referenced. I was lucky enough to be involved in the commissioning of the paediatric cardiac surgery and in the cancer services for Altnagelvin and across into Donegal.

I want to first ask Professor Heenan about research and evidence. I know she has said there is a lack of such, and I would agree with her, but what research and evidence should now be prioritised to set out the roadmap or framework for a comprehensive, collaborative, all-Ireland approach to health and well-being?

What are Professor Heenan’s thoughts on whose responsibility it is? Who will grasp the straw, take the ring and run with it?

Professor Deirdre Heenan:

To answer Ms Cullen’s question, the lack of information and data in this key policy area is extraordinary. Many times, when we hear people talking about it, it is on their received wisdom, anecdotal evidence or long-held views, rather than anything that could be described as evidence. For example, the prevailing view in the North is that the healthcare system is far superior to the one in the South. We frequently hear mention of the fact that this is because, “You have to pay down there to see the doctor or access services.” We want some up-to-date information about access to services. On the one hand, it is fantastic that we have a National Health Service that is free at the point of delivery, but the issue, as Ms Cullen rightly highlighted, is access. We have people waiting for surgeries and elective care for seven or eight years. We have children on mental health waiting lists for years. There is some work being done, but frankly it is tinkering at the margins because we have not addressed the bigger question, which is transformation of our health and social care system.

Ms Cullen will be well aware that we have had seven major reviews in the past two decades. These reviews, such as the Donaldson review, the Appleby review, Transforming Your Care and, most recently, the Bengoa review, have all pointed to the same direction of travel - that we do have enough money for a world-class healthcare system but we simply do not have enough money for the system we are currently running and we really need to make changes. That has been dodged for all sorts of reasons. We could have a long discussion about that, but we are where we are. Instead of depending on anecdotes, it is time that we have serious research commissioned at governmental level on both sides of the Border. This has to be led at least at ministerial level in order that we can agree on the information we want to collect.

My particular interest would be on access to healthcare services. We know we have different systems. We know about the theoretical advantages and disadvantages of those systems. If we were to speak to people who are trying to access those healthcare systems on the ground, we may get a very different picture. I do not just mean access in terms of elective care; it is access to a GP in a timely fashion and access to screening. For example, in the North, bowel screening is at age 60. This is ten years later than it is in other regions of the UK. Why is that? Why are we a decade behind? As Ms Cullen mentioned, Professor Mark Lawler and I have been funded by the analysing and researching Ireland North and South, ARINS, project to undertake work on all-island cancer care. We are particularly interested in what we could do in terms of a whole island approach to tackling cancer. We know that one in two of us are going to have cancer. We know that this is partly because of an ageing population, but we have to get serious about being proactive and preventative medicines.

We talk a lot of the shift left and moving resources upstream, but in fact we are firefighting every single day of the week. Unless we start to address that, we cannot hope to change health outcomes. That whole area of prevention and public health could be addressed on an all-island basis. For example, if a person has depression or a serious mental health issue, does it really matter if they are sitting in Derry or Donegal? What did we learn from Covid-19 about the importance of online services? We know that many young men, for example, would much prefer to have mental services, particularly counselling, available online, so it does not really matter where they are based. We have to think much more proactively. We talk a lot about the existing co-operation across this island. My contention is that it is not enough. We need real collaboration, which is a project where we put our resources together and have agreed objectives and outcomes in the area of mental health or cancer services, for example. We have a ten-year mental health strategy published in 2021 which does not mention the Republic of Ireland. It is as if it does not exist.

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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I thank Professor Heenan very much. I thank Ms Cullen for her questions.

Alison Comyn (Fianna Fail)
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I thank the witnesses very much for coming here today. I have read their reports. They are full of useful information. As a Senator based in County Louth – a Border region – it is difficult for me to know whether it is a great thing or not for the rest of the country because I realise there is a little more reliance on cross-Border healthcare from the likes of some of the Border counties. It is probably serendipitous that the two witnesses here today are women because I wish to ask some questions about women’s healthcare. Our Lady of Lourdes Hospital in Drogheda, where I live, is the de facto regional hospital in all but name. The maternity services there are always under serious pressure as it is the regional hospital for Cavan, Monaghan and a lot of the wider area. Are there any plans to include maternity and neonatal services in any further cross-Border healthcare initiatives?

Professor Deirdre Heenan:

I have been involved to date in the mental health strategy and working in the area of mental health. I do know if the Senator is aware of this but it is a great disappointment to us that after the voluntary community sector and statutory sector worked together to produce a very good mental health strategy, our Minister announced last Friday, ironically on World Mental Day, that 80% of that strategy is to be shelved as the funding is not there to deliver it. That really begs the question from a policy perspective as to what on earth the point is in getting groups together, talking about principles of coproduction and producing a strategy. Very unusually, in this case the Department of Health in the North produced a funding strategy to go alongside that mental health strategy. Many groups on the ground are devastated by this news and the fact that it is simply not going to happen. We do not know where the decision was made. However, my contention would be that politics is about priorities and clearly mental health is not a priority.

Within that we had hoped to see the development of perinatal mental health services. That was to be a priority. We are the only region of the UK without a specialist unit. We had hoped that money would be found but it has not been found. Women in the North are still going to mixed mental health services for perinatal services. It is simply not good enough. We have also been promised a women’s mental health strategy. There is no sign of it. There is no discussion on it. Women have done their very best to push women’s health issues, but again it gets lost in the noise regarding the lack of money and not being able to afford to do this. For that area, it is very difficult to say who are the advocates pushing for a women’s health strategy and how we can ensure that we get more traction in this area. People are being left behind.

Alison Comyn (Fianna Fail)
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Professor Heenan mentioned mental health issues, particularly women’s mental health issues. I mentioned maternity. Professor Heenan is right. There is a broader strategy in this. There are the likes of endometriosis, fertility treatments and all of those. They should be put into some sort of a cross-Border strategy.

Professor Anne Matthews:

I wish to come in on maternity care specifically. We on this side of the Border would have envied maternity care in Northern Ireland because it was a different model of care. It was more midwife-led and more birthing unit than consultant-led. My own research was on midwifery empowerment way back when. A lot of midwives who trained in the UK and came back to Ireland were shocked at the lack of autonomy for midwives in the Irish maternity system. We now have another ambitious maternity care strategy for the Republic. Its implementation is slow.

Unfortunately, it is probably an area where we are seeing a convergence of more negative development than one improving to meet the other. Drogheda was mentioned. There is a midwife led-unit there and there are services in Cavan and Letterkenny linked to various pathways. We certainly need a huge improvement in midwife-led care and community-based and home-based care from midwives. Our system was so based on hospital-based, consultant-led care for all women, whether they were low risk maternity or not. There are all those other areas such as liaison with mental health services and other specialisms which are needed as well. The slow implementation of the Irish maternity care strategy is regrettable.

Alison Comyn (Fianna Fail)
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An issue I found myself was with HRT when I availed of cross-Border surgery through the great scheme we have with the Kingsbridge hospital. However, as a HRT user, it never arose that I would have to stop taking my HRT because of UK policies. Obviously, none of us wants to be plunged into menopause during surgery as well and that is what happens. Are there any plans for a national perioperative HRT protocol for both sides of the Border because there was a huge lack of communication between both healthcare systems where there were mixed messages and nobody knew what the actual strategy was.

Professor Deirdre Heenan:

As far as I am aware, there are no plans. It is quite typical of healthcare issues across this island in that it becomes headline news. People are very concerned about it. There is a scramble of activity. However, in the end, it peters away and no change is made because the view is that was an issue then, it is not an issue now and we will wait and hope it does not become an issue in the future. I do not know of any plans to regulate that or change the rules as they exist.

Alison Comyn (Fianna Fail)
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It seems to be one of those where you only find out about it as it is happening, but that was two years ago and there is still nothing happening. I cannot have been the only person who was affected by that.

Professor Deirdre Heenan:

Not at all.

Garret Kelleher (Fine Gael)
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I thank Professor Heenan and Professor Matthews. Prior to becoming a Member of the Oireachtas, I worked for a private healthcare company. There was certainly huge co-operation between clinicians in the North and South. The company I worked for was focused primarily on respiratory care. The North-South co-operation between clinicians and east-west co-operation between clinicians on the island of Ireland and those in the UK was something that was used to everybody's advantage. It is disappointing to hear the level of frustration that is clear in both of the professors' statements about the lack of co-operation and collaboration on policy.

To assist us in trying to push things further in the area of co-operation and collaboration, I will focus on the few success there have been so far. Professor Heenan mentioned the congenital heart disease network and the success of the cancer centre at Altnagelvin. If Professor Heenan could tell us a little bit more about the positive outcomes, that might help break down the barrier of those with responsibility for policy in both jurisdictions thinking they are better off operating on their own rather than co-operating cross-Border.

Professor Deirdre Heenan:

The north west cancer service is known to most people across this island. The key benefit of it is that people who are in the north west of this island are not asked to travel unrealistic distances for their services. If you are living in Donegal, no one is asking you to travel to Dublin when you can cross the Border six miles away and get services because of an agreement between two Governments. Regardless of what your constitutional view is, geography is geography and this is logical. The logical answer is to go to the services that are closer to you, particularly with cancer when you may be going for multiple treatments, you may not be feeling particularly well and it can be a huge strain on an individual and their families.

When we talk about that north west cancer service, we talk about the logic of it. At one time in Northern Ireland, we had cancer services spread very thinly across up to almost 17 hospitals. When we look back on it now, we ask how we ever thought that was a good idea. In the North, we have moved to a model of specialisation where we have a cancer centre in Belfast and a cancer centre in Derry. It means that people who are specialists are working on a team with specialists. It means that individuals know when they go there, they will be able to see the people who are expert in the cancers they are dealing with and, it is to be hoped, they will be dealt with in an appropriate manner. It is part of a wider discussion in the North about how we need to move from spreading services thinly to having specialist centres. The data exists to show there are better outcomes for people who are travelling those short distances and a high level of satisfaction from people who have used the services.

I was involved in discussions about the congenital heart disease network with the then minister, Edwin Poots. It is often said we cannot develop these services because of political obstacles. The then health minister was in the DUP and he was very supportive of the idea of an all-island congenital heart network because of logic, common sense and the realities of asking people with sick children to get on helicopters and go to services in Birmingham or ask them to go an hour and a half down the road to special services in Dublin. I firmly believe that health is one area where we can no longer say this is because of political sensitivities. I do not know any politician, North or South, who could say I do not want to do this because of a constitutional issue. This is about better health outcomes for people across this island, regardless of their political persuasion. It is important to put that on record because sometimes that is held up as an obstacle or a barrier. That is not my experience.

On the congenital heart disease network, it happened because of very invested individuals who worked night and day to make sure this happened. They were doing this on top of their day job. They were doing it because they believed in it. That is how we largely ended up with something we have now. The difficulty is if that is the system we have developed, when those people invariably retire - it is to be hoped they get a retirement - or move on, that impetus is gone. That is not a sustainable health model. What I would like to see is, using those two as exemplars, some serious policy discussion to see where are the other areas that we could identify where we would at least have ministerial support to have a scoping exercise in the first instance that could examine what are the possibilities for sharing resources, knowledge and ensuring better outcomes for our population in the end.

Garret Kelleher (Fine Gael)
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I thank Professor Heenan for a very common-sense answer. I appreciate that. On Professor Matthews's comments on midwifery-led care as opposed to what we might be more used to, which is the consultant-led model, I have a few questions specifically on home birth, an area that would be primarily midwifery-led. Does Professor Matthews see scope for co-operation between the two jurisdictions in that area?

Professor Anne Matthews:

Very few women access home births. One of the problems with the systems over time has been the fragmentation of home birth services away from the hospital delivered services. In Drogheda, which we were just talking about, integration has improved along with governance of home births within the overall maternity system. It is really important for women to see that as one integrated system based on the care they need when they need it.

A very small number on either side of the Border access home birth care. The important thing is to have a pathway so that, if it is not working, there is access to the maternity service in a hospital or birthing centre.

Ms Claire Hanna:

I thank our witnesses. This has been a really interesting session. Of course, it is core to the politics of right now. People's living standards should obviously be at the centre of everything elected people do. It is very much at the centre of how people will think about the future of this island, including our constitutional future. There is an opportunity to build something better and new. I have just finished the book by Fintan O'Toole and Sam McBride bringing forward arguments both for and against constitutional change and health features strongly as both an opportunity and a challenge. The book mentions how jurisdictions on both sides of the Border struggle to properly integrate services but it ultimately comes down on the side of there being an opportunity to make something that is better than the sum of its parts.

Last month, my Assembly colleagues brought forward a motion about CAR-T treatment for cancer on the back of the case of a young mother who spent her last six weeks in a hospital in London, away from her three children. She ultimately died of cancer and did not get to spend at time at home when the treatment she needed was available about an hour away as she lived close to the Border. Our system drove her to London, meaning that she and her husband were away from the children as they went through that experience. It makes no sense.

I was struck by Professor Heenan's comment that, where we have made gains, they are in large part as a result of really motivated individuals and really determined campaign groups, people like those families who are trying to fix a problem they have had to face, rather than the result of systemic approaches or politicians on either side of the Border grasping the opportunity. I will ask a few questions. Do we use the existing cross-Border mechanism adequately and appropriately? I hope I will be forgiven for making a political comment but the North South Ministerial Council is like a polite tea ceremony. It seems to meet and go through the motions but I do not think it meaningfully changes politics. The opportunity it presents is not being grasped in the way people thought it would be in 1998. Is there any more low-hanging fruit? Are there gains we could realise quite quickly within the operation of our current models? Are there continuing workforce issues? There is obviously an existential issue in that workers are mobile and understandably feel able to work in systems that give them the chance to practise safely and comfortably rather than the more chaotic system we have North of the Border. Is there fluidity that allows people to transfer between the systems? Are the witnesses aware of any international examples we could take inspiration from, particularly with regard to integrating two health systems in different political jurisdictions? Has anybody done that well? Are the witnesses aware of co-operation happening across borders in other comparable parts of the world?

Professor Deirdre Heenan:

As we have already said, health is an established area of North-South co-operation. One might have imagined the North South Ministerial Council would have grasped that nettle and moved the issue forward. I was interested in Ms Hanna's description of it. It does sometimes feel like an afternoon tea party. In terms of serious public policy, it is a missed opportunity. We are told ad nauseam that health is an established area of co-operation. We have to interrogate that statement and ask exactly what it means. Does co-operation mean that I tell you what I am doing, you tell me what you are doing and we have a nice cup of tea while we discuss it? That is not good enough any more. We do not have a committee to drive this forward. Looking back on our record in the area of health, including public health, you find that, if there is no strategic leadership, these things are talked about and then fall off the agenda until they are talked about again. That is very difficult.

I did a scoping study for the shared island unit. I spoke to consultants and others at the coalface to ask them what they thought. What really struck me was that no one said more co-operation would be a bad thing. There was universal agreement that there are many areas in which we can co-operate to achieve better outcomes. However, they were also concerned that, if you say this to the people in charge, you will be told the data systems are different, the information is different, the systems cannot speak to each other and there is no way to know whether outcomes are better North or South. We have been using that as an excuse for almost three decades. It is not beyond our wit to produce data sets to give us a robust understanding of outcomes North and South.

Of course, the world and his wife are talking about AI so I will have to introduce it into this conversation. Could AI be the mechanism whereby we make it possible to use data North and South? Then we need a way of sharing information. Quite frankly, on an island this size, it is bizarre that things are going on across the island that people working in the same area have no knowledge of. They may accidentally run into someone who works in the same area. This is not just an issue in clinical practice but also in research projects. We find people saying they heard about someone or read about their work and asking to collaborate because the information we have is invariably out of date and the websites we have are not maintained because project money has run out.

This is a really serious issue. If we are going to have change in this area, where is the leadership going to come from? Both healthcare systems are under stress. We are realistic. Who is going to put their head above the parapet and say that, while people are knocking at their door demanding to know what is happening about health in their area, they believe we should prioritise North-South collaboration? It is just not going to happen unless an external person comes along and says this should be a priority, that we need to agree it is a priority and that we need to agree what that priority looks like. I do not know where that is going to come from. There has been an awful lot of talk about it. After the Covid-19 pandemic, we were told that we had learned lessons and that we understood the importance of better collaboration. The key word here is "leadership". Where does the leadership in this area come from if both our health Ministers are working frantically to deal with difficulties in their own systems? As it is not realistic to expect that they will suddenly offer their services, it has to start at a joint governmental level. I would have thought the North South Ministerial Council would have been the ideal vehicle. We have a road and we have a vehicle. I do not know how we get the two together.

Professor Anne Matthews:

To go back to living standards, housing and poverty, including more recent reports about poverty, these are all the problems the healthcare system has to deal with. As Professor Heenan has said, we have problems in the health system, including a lack of capacity and the lack of staff Ms Hanna mentioned, an issue on which we are running to keep up and where there is huge international recruitment of all healthcare staff across the two jurisdictions. If those kinds of determinants of health were tackled, there would be less pressure on the health system, allowing some capacity for this kind of work. Obviously, it is not that simple.

Professor Deirdre Heenan:

May I very briefly go back to Ms Hanna's question on workforce challenges? If you speak to anyone in the north-west region, Derry and Donegal, they will say that the NHS is being hollowed out by the system in the Republic.

Terms and conditions are so much more favourable on this side of the Border that it is, of course, understandable that people will say they are going to leave the NHS because it does not look like it is getting any better in the short term, and are deciding to move and take their skills with them. Perhaps, the answer-----

Ms Claire Hanna:

In many cases, they want to practise safely in an environment where they can give their patients the best care. They are not finding that on this side of the Border.

Professor Deirdre Heenan:

The longer that goes on, the more of a problem it becomes.

Frances Black (Independent)
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I sincerely thank both witnesses for coming in. Many of our upcoming discussions at this committee, particularly on health, will be the first of their kind, at least on this scale. In the spirit of that, we are aiming to achieve something that has not been done. That is what the vision is anyway. We know there is a huge gap in this space. There is no doubt about that. I would love to see us build that roadmap for all-island healthcare the witnesses spoke about, or at least lay the foundation for that. I know that is something they are asking for today, in particular.

I have a couple of questions for Professor Matthews. I will ask them all together so she will have time. She mentioned the different models for providing universal primary healthcare services and the contrast between the NHS and the HSE in delivering these services. Does she think the disparities are limiting our ability to build cross-Border initiatives? Are there any lessons to be learned from that? If there are any lessons, what are they?

In Professor Heenan's article, which she mentioned, and I love the idea of this, she proposed the establishment of an all-island health committee. It is an absolutely great idea to have an all-island health committee that could produce papers on possible areas of collaboration, such as procurement of services, staff training and the sharing of knowledge. Has any work at all been done on that since she published that paper?

I have a final question on the ESRI report that Professor Matthews shared with us. It was really helpful in understanding the primary care systems in both jurisdictions. The report acknowledged that the research was hindered by the lack of comparable data. One of the reasons for this was that many of the data sets report on the UK in its entirety rather than treating the four constituent countries separately, so health system metrics are measured differently. The report stated that alternative sources would be needed to study system level characteristics or indicators like workforce and expenditure. Have either Professor Heenan or Professor Matthews looked at this in more detail? Will they highlight specific areas or indicators that should be prioritised? Those are my questions. I have given them a lot there.

Professor Anne Matthews:

I will make a start. I thank the Senator for highlighting the question of eligibility for primary care in the Republic. Professor Heenan highlighted that having eligibility does not mean you can access, let us say, a general practitioner. The reason I wanted to emphasise Sláintecare was it is a ten-year all-party strategy, which is very new for health. It was backed by all parties that universal eligibility would be fundamental for primary care, as Ireland was the only country in the OECD that did not have that. It is almost like until that is reached, there is almost no capacity for the other parts of the system to improve. There has been an enhancement of community care, community care networks and primary care services as part of Sláintecare. It would be mistaken to think, however, of eligibility next being increased to 12-year-olds - over-70s have it without means testing and it is going in that piecemeal fashion - when the bigger problem is capacity of the workforce, including general practitioners, practice nurses and all community health professionals. That is the case for both systems. Are there disparities because of that? Probably not, given that there is a means-tested system as well within the Republic so, hopefully, income is not a barrier. Obviously, there are thresholds where people go over that.

The ESRI report was really good. That was an example of funded research that came out of the idea that we should focus on healthcare in a cross-Border way. Having the ESRI's expertise and resources to be able to come to that sad conclusion about data not being disaggregated is a real barrier to any of us. I see it in trying to track workforce movements where they are not separated by which parts of jurisdictions people come from. It is a huge challenge. I do not think there has been any development on the committee, but Professor Heenan can answer that.

Professor Deirdre Heenan:

As far as I am aware, there has been no development. It is my personal view that we will not move this area of policy forward until we have an all-island healthcare committee that has some ability to set out a strategic direction. What we have at the moment are well-meaning people working in areas where they are convinced they can make a difference, but it is an extraordinarily difficult ask for anyone who is already working in an overstretched healthcare system.

In terms of the two systems, sometimes, an awful lot is said. We need to take a step back and realise what the situation is, particularly in the North, which I know more about. Pre Covid, for example, we did some research in the north of England. We looked at a healthcare trust that had a similar population and similar population size to the North. In that area, ten people were waiting more than one year to see a consultant and this was deemed to be outrageous and shameful. The comparable figure for the North was 120,000. I say that because, sometimes, people hear that the system in the North is struggling and it washes over them in the same way as when we hear statistics, we sort of glaze over and think, "Have we not heard this before?" It is important to use those sorts of statistics to highlight how far behind we are in terms of our healthcare system.

With my other hat on, as someone who studies governance and models of devolution, I often say to our secretary of state our devolution settlement was based on the principle of parity between the devolved regions. How far out of kilter do we have to be in terms of our health and social care system until it is suddenly decided that we are not full citizens? We are so far away from an English system where it has just been announced that no one will wait longer than 18 weeks. We are asking people to wait eight years. Again, these are numbers but these are people waiting in pain, waiting without hope and dying unnecessarily.

Alongside this, almost in a parallel line, we have a conversation about economic inactivity rates in the North, as though the two were not interrelated. When we talk about the health committee, maybe the way to sell it is to say health is all of our business and is an economic issue. If cancer or some sort of health issue arrives at your door, that has a serious implication for your ability to be a taxpayer and to work and for your family, who may have to take on caring roles. Sometimes, health is viewed in isolation. People feel it has gone so far, they do not know where they would start. A much more logical way to look at it is the financial, economic, social and political implications of health. I cannot think of anything more important.

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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I am not sure whether Mr. Mallaghan or Mr. Maskey, who are online, want to ask questions. There is a slot here for the MPs.

Mr. Cathal Mallaghan:

I thank Professor Heenan and Professor Matthews for their presentation and answers to the questions so far. Professor Heenan probably already touched on this briefly, but I want to follow up on the likelihood of patients in the North frequenting their GP practices more often than those in the South. We know there is a barrier there in terms of payment, but it is also reflected whenever we see accident and emergency appointments, where the population is three times greater in the South, but we only have double the amount of people attending accident and emergency. I would like to hear the witnesses' thoughts around that and what difference it has made, particularly when life outcomes in the South are two years greater.

I also wish to hear their views about the fact that there has been no paediatric pathology service in the North for seven years. Diseased children are instead sent to Alder Hey Children's Hospital, Liverpool. It is terrible that the commitment given to establish an all-island paediatric pathology service has not moved forward yet in any way.

On a brighter note, the fire and rescue service's learning and development college, LDC, opened in Cookstown recently. While that is a Department of Health issue in the North, it sits elsewhere in the South. The opportunity now exists for an all-Ireland centre of excellence for fire and rescue services. While there has been some disappointment with the lack of progress in certain aspects of our healthcare, at least this is one silver lining where things are improving.

Professor Deirdre Heenan:

That was insightful. To start off, with regard to admissions and people turning up at accident and emergency departments, there is a serious problem in the North with GPs and GP funding. GPs in the North are funded to a much lesser extent than their counterparts across Britain. It is historic. They used to attract almost double the health budget, but it has been reduced year on year. We cannot seem to find out where that decision was made or who made it. What we know is that post Covid-19, people in the North have real difficulties in accessing their GP. We hear that daily on phone-in shows and when we are out undertaking research.

There will, of course, be this debate that it is the fault of the GPs, who must be off playing golf or sitting at home in their pyjamas. If people visit a GP multidisciplinary team, however, they will see how overstretched they are, what they are expected to do on a fairly limited budget and how many people they are expected to see. Of course, the issue for GPs is being able to see people in a safe fashion so it is not a production line. The GPs in the North are under severe pressure in terms of capacity and reduced funding. I do not know whether the committee is aware that they are in a dispute with the Minister regarding the amount of funding they have currently been allocated.

Of course, if people cannot get access through the GP, where is their next port of call? They are going to turn up at accident and emergency departments. They will be willing to sit for 12, 24, 48 hours, or as long as it takes to be seen. It is an entirely inefficient and ineffective system. We do not want people, for example, to receive a cancer diagnosis in an accident and emergency department. That is utterly inappropriate.

We also feel that this system has almost become normalised. People are of the opinion that if they cannot get access through one service they will go to another. If we are going to radically change the issues we see year on year in Northern Ireland, we have to start with the GPs. They are the gatekeepers. They are being asked to do more with less.

As we look into winter pressures, we have to set a winter pressure plan with nowhere near enough emphasis on the fact that most people who feel unwell will go to their GP in the first instance. That, in a large part, explains why we have so many more people putting pressure on the accident and emergency department to the point where the accident and emergency system cannot cope.

In the North, on any given day, whether it is in May, June, July or November, there are 500 people sitting in hospitals who are medically fit to be at home. Why is that allowed to happen? Why is that not a number one priority in our healthcare system? It is emotionally and physically damaging on those people, who are medically fit to go home but remain in a hospital. It is also an inefficient use of resources. Yet, we seem surprised when it happens month on month, without any ability to ask about step-down facilities, district nursing services or acute care at home. We know what the answers are but we seem surprised that we still have the problem.

Professor Anne Matthews:

There are similar issues regarding the flow between GP services and emergency departments. The complicating factor in that regard is whether people are paying for their GP or paying an emergency charge. They are making slightly different decisions. The emergency departments are under huge pressure, however. Similarly, it is not where people should be finding things out. That should happen way back at the community level with the primary care team.

There have been a lot of developments in that enhanced community care with greater nurse-led services in primary care, that is, the general practice settings and other public settings, for things like chronic disease management, which can be fully nurse-led and nurse-delivered. It is just about that whole capacity issue.

From looking at workforce planning over the years, general practice is so vulnerable to retirements. People are unable to take holidays. When more female GPs wanted different hours of practice, that was built into these workforce models, which were showing a massive strain over the past ten years, but that is increasing. There are definitely the same pressures as well about people trying to find suitable homecare that is funded by the system to the same level as funding for nursing homes through fair deal or other provisions.

Rose Conway-Walsh (Mayo, Sinn Fein)
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I thank the witnesses for being here today. It is an important session. It is the second session we have looking at an all-island healthcare system. As both witnesses alluded to, what an all-island health service would look like is one of the key questions people want to know. It does not matter what age people are or what community they come from; it is a key question we are trying to answer on this committee. I am particularly interested in expanding on what Professor Heenan said, “However, without a framework and a vision for collaboration, interventions will remain fragmented and piecemeal.”. I wish to get to that idea of a framework and what specifically we need to do in that regard.

As a party, we in Sinn Féin published a policy document entitled The Case for an Irish National Health and Care Service, which made some recommendations. It is a discussion paper that was launched by Deputy Mary-Lou McDonald earlier this year. The first proposal in the document is that:

The Shared Island Unit should develop detailed costings for implementing the Sláintecare and Bengoa reports and also develop costed proposals for integrating the health systems in the north and the south as a single universal healthcare system. Both these reports should be considered as a potential roadmap when designing a new Health and Care Service.

The second proposal states:

The Ministers for Health, north and south, along with an Assistant Secretary General (or equivalent) from each Department of Health should lead design, planning, integration and collaboration on an all-island basis. The HSC Trusts in the north and the HSE Regions in the South should be part of this process.

I wish to get at the idea of a framework and what needs to be done. While a lot of good stuff is being done, as Professor Heenan rightly says, it is being done on a project basis. I acknowledge the great work being done by Professor Mark Lawler as well, at Queens, in the cardiovascular research area. We hope to have him as a witness on this committee as well to learn from that and what can be done in that regard. We also will be inviting the Minister of Health in the North, Mr. Mike Nesbitt. I hope he will take part in our discussions as well because, as Professor Heenan said, regardless of people's constitutional preference, we need to know what an all-island health service would look like. We all have a responsibility in that regard. Will Professor Heenan speak a bit on that framework piece, how she would see it being instigated and who would lead it? I also ask her to speak on the first two proposals in Sinn Féin’s policy document.

Professor Deirdre Heenan:

It is my strong view that we need a strategic framework in order to agree priorities, objectives and funding. What we have had to date is all sorts of promises where politicians and policymakers tell us that health is motherhood and apple pie and who could argue against it. Six months or 12 months later, however, we are no further forward.

That is because no named individual is responsible for taking this agenda and running with it. Neither of the two health Ministers will voluntarily take on this job, probably because both of them are stretched to their limits. The shared island is a perfect vehicle to ensure health becomes a priority. It is not just about a little project that is time-limited and then finished, and does not become mainstreamed.

Looking at it from the North, there is a view that when both Governments were co-operating and working together on this project in the Border regions, it was responsible for some remarkably innovative work but that work was largely project-specific and not mainstream. When the work on eating disorders was finished, it was finished. The project was a useful way for both Governments to say, "Look over there. That's what we're doing. We've ticked that box. We've answered your question." It is not answering the question; it is project-specific, EU-funded and in the Border regions. The word missing in all of this is "ambition". If you look-----

Rose Conway-Walsh (Mayo, Sinn Fein)
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Professor Heenan is saying that the shared island unit could do this. This is where she would see it as well-----

Professor Deirdre Heenan:

Yes, that is where I would see it.

Rose Conway-Walsh (Mayo, Sinn Fein)
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----so she would agree with our proposal that the shared island unit should be given the extra capacity it needs to develop this, bringing together the two Ministers and the executives under the Ministers.

Professor Deirdre Heenan:

I absolutely agree. The shared island is an ideal vehicle for sharing knowledge and information, for agreeing objectives and then for agreeing funding. The funding may in the first instance involve finding out, if you will pardon the expression, what the lie of the land is and where we are in terms of our healthcare outcomes. We depend on data that is not very reliable but it would not be beyond the wit of academics across the island to change that. If there is a joint project, we need to establish a baseline and work out where we are and where we want to go. What is the destination? As the Deputy said, this is not about constitutional preferences. Everyone should want to ensure such a large tranche of public funding is well spent and people get the best possible outcomes.

Rose Conway-Walsh (Mayo, Sinn Fein)
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We proposed that in the group would be social care professionals, health economists, senior management, professional organisations, trade unions and relevant experts from both jurisdictions to be able to implement that.

We have also proposed the establishment of a single, integrated hospital waiting list system for the island of Ireland. Is that feasible? Should it be done?

Professor Deirdre Heenan:

In the North, we do not have a single system. Part of the difficulty with our healthcare system is that we have five trusts and an ambulance trust. Those trusts run their own lists. We do not know if priority, decisions and policies are the same in those areas. I do not think that is a satisfactory way to run a healthcare system.

Rose Conway-Walsh (Mayo, Sinn Fein)
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I will ask Professor Matthews as well. Does she think an integrated healthcare list would work? If somebody was waiting in a certain area, you would be able to see if there is a vacancy down here or whatever.

Professor Anne Matthews:

Both systems are under pressure with waiting lists. This goes back to the real problem. There are myths about each side of the system suggesting that is better and this is not. As Professor Heenan and others have said, we need fundamental facts about how these things compare. We would hate to end up with a worse overall outcome for everyone.

I was thinking about what has been said about Sláintecare. Sláintecare has focused on eligibility. Despite all the HSE reforms since it was established, things have fundamentally not improved in terms of eligibility. It is putting eligibility over here and the ongoing HSE reform agenda is still rolling out. It is a moving feast a lot of the time. I am not sure there is the capacity in the HSE and that reform programme. It would be great to hear from people leading the HSE reform about what capacity there would be for that.

Rose Conway-Walsh (Mayo, Sinn Fein)
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If you had a digital health service, I suppose if you had digital healthcare records-----

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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Deputy, time. There are other people to come in.

Rose Conway-Walsh (Mayo, Sinn Fein)
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I know, but if you had that, it would play a key role as well.

Professor Anne Matthews:

Absolutely, 100% priority.

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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Fair point. We will bring in others because people are waiting. I thank the Deputy. She can come back in the second round. I call Senator Blaney.

Niall Blaney (Fianna Fail)
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I thank the Cathaoirleach. I welcome Professors Heenan and Matthews and thank them for their presentations and the open discussion.

I come from the north west so I am pretty much aware of the cardiovascular and cancer services available. The first point I would have to make is that it is paid for by the South. What services we get, we pay for. Number two, we have no input into how those services are provided. Number three, we play the second fiddle. If those services are at their peak, we do not get access to them. Maybe they are not what they are portrayed to be. They are fantastic services but there are improvements that could be made. They are a catalyst for similar workings across the Border. Justin McNulty has been in my ear and colleagues' ears in relation to Daisy Hill and how it could share services with counties south of the Border in a range of areas. There are many other hospitals in the same boat.

I am struck by the witnesses' comments. As a politician, I realise not everything is rosy in the garden in Northern Ireland. If it was, our health service would have been sorted long ago, as would our police and education services. I do not believe it is as simple as two Ministers coming together and agreeing everything and then everything is rosy and dandy. We know that has not happened in the past and it will not easily happen now. There is a lot of work to do. I would like access to more stats and I thought I would have had more stats on health services North and South from today's presentations.

Am I to take it from what Professor Heenan has said that the research going on is insufficient? Is she saying the research done through shared island is not at a level that will identify deficiencies in health services, North versus South? It is important we establish those facts. Before we put the cart before the horse, we need to establish the facts. The facts are the most important thing.

This will not be agreed by two Ministers. It is a much bigger picture in the constitutional question. That is why this cannot be rushed and the research is so important. While it is good to get bits and pieces done, we will not get answers to all our difficulties on a cross-Border basis. It is important we get to the bottom of where we are at and the different categories of health.

What impact, if any, will the £37 million into the health school in Magee-Ulster University have on cross-Border health services and provision of health services? I have not seen that mentioned.

Over the past ten years, through Covid-19 and other factors, Stormont has been down more times than it has been up. How much impact has that had on cross-Border sharing of health services? Now we are back at the table again and, thankfully, Stormont is working again. Relations have had to be rebuilt. These have to be factored into building relations because relations were damaged. They were also damaged by Brexit. As the witnesses know, politics is not simple.

Professor Deirdre Heenan:

Thank you for your question. I agree we are living in a post-Covid, post-Brexit landscape and they have dramatically impacted on policy and the policy agenda. If Tony Blair's mantra was "education, education, education", ours in health should be "evidence, evidence, evidence".

We cannot be grappling around in the dark based on anecdotal evidence. It is the job of the shared island unit to develop and produce that evidence or at least make it easier for us to put evidence together in way that it makes sense and everyone can see the logic of what we are saying.

Niall Blaney (Fianna Fail)
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Does Professor Heenan mind if I ask the question differently?

Professor Deirdre Heenan:

Go ahead.

Niall Blaney (Fianna Fail)
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We are told that 62 pieces of research are being done by the shared island unit. The assumption is that health is all over this. Is Professor Heenan saying that it is not part of the research being done?

Professor Deirdre Heenan:

No, I am not saying that at all. There are specific healthcare projects that may be on mental health or cancer and they are valuable in themselves. However, this is a different issue. This is about cross-Border collaboration. This about a policy agenda across the island. It is a very different project to, for example, looking at how AI might impact on our cancer outcomes, which is a worthwhile project. The shared island unit has to say that part of its remit is to have a scoping study and set out robust information for all interested parties. We now have the encompass system in the North. It is a digital healthcare system where we are able to produce information that we could not produce before. We had some teething issues but we have moved on.

I agree with the member's assessment that two Ministers cannot get together and decide that this is a priority, given that they are probably the most overstretched Ministers of any Government portfolio. This has to happen at the Good Friday Agreement level - at the intergovernmental level - where there is a decision to say both jurisdictions would benefit from a different approach. It is about an ambition to do better with what we have and that can only be underpinned by a political agreement. It seems very difficult.

I had a wry smile when the member said that we would not want to go too fast. I do not think that we could go any slower on this. We have been talking and talking about it. When one speaks to clinicians in Daisy Hill Hospital and Altnagelvin Area Hospital, they are deeply frustrated. It is not as though they are saying we should not push this agenda forward. They are saying it is difficult for them to raise their head above the parapet to say there are better ways of doing this and that may involve more cross-Border-----

Niall Blaney (Fianna Fail)
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Is Professor Heenan saying that the scope of the research by the shared island unit is not deep enough? From my perspective, the research is going to decide the policy. Without the research, there is no point in putting policy forward.

Professor Deirdre Heenan:

No, I am saying that the research that the shared island unit has supported is in many cases excellent. It is first-class research, but it is project-specific on particular things such as healthcare imaging, cancer care and other areas of care. It is not looking at the policy agenda. We have an economic policy unit in Ulster University. Given that we spend 52% of our block grant on health, it is extraordinary that we do not have a health policy unit in the North. We spent £8.6 billion on healthcare this year. We should be understanding what other countries do and what can we learn from them. I am going back to visit Professor Raphael Bengoa in the spring. He has always said that the changes he made and was able to deliver in the Basque region were based on the fact that there was political will. When you ask him what was the most important ingredient, he does not say money, equipment or AI. He says the political will to make the changes.

David Maxwell (Cavan-Monaghan, Fine Gael)
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I thank the witnesses for attending. I am a Border TD and live in Monaghan. Like my colleague Senator Blaney, I was shocked when the witnesses said how poor the services were in Northern Ireland. I know that from having family living there. I believe that the Executive gets one of the top rounds of funding for health services in the UK from the UK Government. I could be challenged on that.

We talk about political will and coming together on both sides of the Border. For the past 15 years, I have been listening to talk about the closure of the accident and emergency units in the South. The unit was closed in Monaghan General Hospital. Sinn Féin is constantly harping on about how it should be opened. The Taoiseach was the then Minister for health. He was blamed in the last number of weeks for being the cause of the closure of the accident and emergency unit in Monaghan hospital. It then came down through James O'Reilly right up to the current Minister for Health, Jennifer Carroll MacNeill, who is somehow being blamed about the services.

It maddens me, ad is probably the reason we do not have that cross-Border collaboration, that Sinn Féin in Northern Ireland took the exact same logical look at the reports that were done from the year 2000 that said Northern Ireland had too many accident and emergency units. I think six or seven were downgraded to minor injury units. Sinn Féin did it in the North but it still says that we should not have done it here.

Nobody in Monaghan, Armagh or Tyrone is going to complain if they can get a better outcome whether it is in terms of CAT scans, MRIs, cancer, strokes or any disease. If a family member gets sick, we want the best treatment and will travel to get it. We have a cluster of four hospitals where I am. We have Monaghan and Cavan, which work as a one-unit hospital. Cavan is the more senior and has the accident and emergency unit. Monaghan is doing the day cases and has a minor injuries unit. Just across the Border we have Enniskillen, which is closer to Cavan, and we have Craigavon, which is closer to Monaghan. My fear is that with all of this better collaboration, services will be taken from Monaghan to Craigavon because it is a teaching hospital - it has all the bells and whistles - or Cavan could lose out to Enniskillen. I believe that not all of the theatres are up and running in the hospital in Enniskillen at the minute even though they could be.

It is great wishing for all this cross-Border collaboration and everything to work, but when you are living on the Border, the fear is that you are going to lose services in your area. Logically and in the best interests and outcomes for patients, that is what is needed, but it will be a hard sell on the ground. It was bad enough losing our services from one county to the other in our constituency. It was the same for Dungannon when it lost its accident and emergency unit to Enniskillen back in the day. However, if we are going to start losing them across the Border or vice-versa - if services come from the North into the South - that will be a big hurdle for politicians to sell to the people. It is all rosy talking about it but when it comes to putting it on the ground, we know how people will turn and say that idea is not for them.

Professor Deirdre Heenan:

It depends how we frame what we are trying to do. If the public listen and hear "closure", "removal of services" and "things being taken from us", we cannot expect them to be happy. We cannot expect people from south Down, the rural area I am from, to say it is how great it is and offer their congratulations on more things going to Belfast, etc. These are the conversations we have.

In healthcare more than any other area of policy, this is about communicating with the public and working with them. It is not about the closure of hospitals. I am old enough to remember when Banbridge Hospital closed. The people of Banbridge thought it was the end of the world. Now, they cannot imagine that hospital being there because they have something that replaced it, namely, a multidisciplinary healthcare centre that serves their needs. The difficulty - I can only really speak about the North - is we do not have an overall plan for healthcare. If we had that plan, people would have confidence that it was not just about removing, removing, removing. Going back to my Tony Blair analogy, it is part of a grand plan. We would have evidence to say that people would have better outcomes. The question for the public is whether they want this service on their doorstep where they turn up in the middle of the night for gastrointestinal surgery with someone working on their own as a locum who perhaps has not carried out this operation before and the member of the public ends up with a colostomy bag, etc., or do they want to travel 20 minutes down the road to a team where they will walk out the next day as though it had never happened.

It is not just about saying, "I want this on my doorstep"; it is about saying the reality is that most medicine now happens in teams. We cannot have a team in every hospital. It is not physically or economically possible. Within those conversations we also need to ask what the role of Daisy Hill Hospital is. Will it be the specialist for orthopaedics such that it is kept open, it becomes a flagship hospital and everyone knows that if orthopaedics are needed that is where to go? What are we doing in the SWA Hospital? Why are those theatres not open? That is a public-private finance initiative we are paying for. There are big questions to which the public need answers. I think that if the public were convinced that in the end this would lead to sustainable, better health outcomes for them, their children and their grandchildren, we may not see as much resistance as we might think.

Finally, this goes alongside saying that if someone says to you it is 10 miles away and you are travelling 10 miles up the motorway, it is very different from travelling around Hilltown, Kilkeel or Rostrevor on roads with potholes and poor conditions in the winter, so we have to be cognisant that we often do not compare like with like.

Professor Anne Matthews:

We talked earlier about cancer services. That was quite an unpopular move in the Republic as well but was part of the national cancer strategy, which was strongly led politically and clinically, moving from local services to specialist centres. There is that public tension. It is difficult for a local politician or a politician with a geographical focus to answer that question from the public. It is also said that everybody wants a better outcome. They want longer survival for people and they want the specialist service. It is a really difficult one. Like Professor Heenan said, if the public trusted the overall planning and maybe the system, some things would go in their favour and maybe some would not but, overall, people would benefit. The North West Cancer Centre is probably an example of where people were happy to go over the Border for better care and more convenience than travel. It was trying to combine both of those. They are complex-----

David Maxwell (Cavan-Monaghan, Fine Gael)
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I will finish briefly. Coming from Monaghan, I can drive to Cavan or Drogheda. You may be in Northern Ireland. We are lucky enough to be able to attend Craigavon but the issue is the waiting time when you get there. People blame that on local services having been removed and the pressure put on the centres of excellence, as they are called. People get peeved that they have to wait six, eight or ten hours in an accident and emergency department just to get seen. There is a bit of work to be done there. If you could get seen within, say, three or four hours, people might accept it more, but you may have to sit for ten hours. Many people say, "After eight hours, I just said, 'I am going home.'" Now, if they say they are going home, was their condition that serious? However, it is making it harder to sell any reason that services have to be moved.

Professor Deirdre Heenan:

May I finish on that? It is entirely reasonable for people to say that because they should not be in acute care. They should be in primary care or community care. We have promised that for two decades but they still end up in a hospital.

Seán Crowe (Dublin South West, Sinn Fein)
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This is an interesting conversation. If we are talking about the problems of the health service in the North, we have to look at the bigger issue as to what has been happening. If you talk to someone in Liverpool about their health service, they will mention the same problems, and who will they blame them on? They will not blame them on Sinn Féin. They will blame them on the Tories, who have stripped the British health service, including services in the North. There are challenges in that regard.

It makes sense that if you are rolling out services in a particular area you have some sort of spatial idea of the cohort in the area. We have limited money, limited services and a limited number of people working within those services. The plan at the moment is to try to have those specialist services. It is a lucky hospital that has people waiting ten hours. It is not unusual for people to be waiting 30 hours. I had a meeting with Tallaght hospital just two weeks ago and we were talking about the challenges there. It is about the step-down beds, the beds within the system and so on.

We are not really here to talk to the witnesses about that; we are here to agree that there is potential for a better system. It is not this narrow "it should not be taken out of my area" view that we will hold what we have and not look at the bigger picture that will work for people. We may need data in relation to that spatial strategy, and that may not be happening. The suggestion here this morning is that if we were to look specifically at the shared island unit, that would help. Maybe that is a recommendation to be made. It does not take away from the 62 pieces of research that are there. Maybe we will park that.

Within the current system, there is a lot not working. As the health committee, we visited Altnagelvin. If you have a heart attack or cancer, it works for people in that cohort. There is the specialist system there. It does not work, however, if people have to do their follow-up in Galway or pass the hospital to do that. That is something people do. I went to Daisy Hill and they were saying that the theatre there is not working two or three days a week. The worry there is that the hospital will close, which would impact that whole region. This does not happen just to people north of the Border. We have a resource there. We have the staff to resource the theatres where we do not in the South. There are children on waiting lists. One thing that popped out at me was the number of children looking for oral health. There are theatres there that could be used for that.

If this is going to work at all, we need to combine our efforts and look at what we have and what would work. Perhaps the finances are here but the staff are there. We all know that health issues do not stop at an imaginary border. This is cross-Border stuff so we need to work together on it. I think that is the approach. Do the witnesses agree?

Professor Deirdre Heenan:

I definitely agree. It is important to put this in the context that we have similar problems, issues and concerns north and south of the Border. Probably the biggest one is the ageing population. Sometimes I get frustrated when people say that because it sounds like it is a bad thing. It is definitely better than the alternative but we talk about it as if it is in some way a disaster. It is the biggest achievement of modern medicine that we now hope to live well into our 80s, but that comes with issues around comorbidities, and we know that older people are disproportionately represented among users of the service. When we get into old age we are much more likely to turn up to accident and emergency departments and to see the GP. Is it really not possible to have much more emphasis on prevention and care at home? Most people want to be cared for at home. They do not want to be in a hospital environment. We should spend more money on falls and on educating people on vaccination and on how to keep their homes warm, for example by saying that if they cannot afford to heat the home they should heat the person. These are all important messages. I think the problem is that this is so fragmented and piecemeal that we end up being pulled in this direction and pulled in the other direction. What if we had much more strategic planning and much more emphasis on the people who are likely to use the services and money where it is required at the earliest possible stage, going back to the GPs?

The BBC once did an interview with people sitting in an accident and emergency department and there were people who quite clearly had no business being there: people who wanted repeat prescriptions, people who had headaches, people who had all sorts of things that could have been much better dealt with by other parts of the service. That is not to blame the individual; that is to say we have a serious communication problem between the health service and the public as to what is best to do when something happens.

Professor Anne Matthews:

The Deputy's points are well made. I refer to the focus on the spatial. Logic was talked about earlier. It is not ideological; it is logical. One of the points Deputy Conway-Walsh made at the end - we did not have the time for it - was on the lack of an electronic patient record. This is back to the hospital setting in the Republic. Communication between parts of the service in the Republic cannot work. I refer to the HSE primary care. Some pieces of that are improving, especially in maternity care, but it is really slow.

That goes back to the comments about the research that is being done. Research often highlights problems with the infrastructure like data and management data sharing. That needs investment; it does not really need more research. We cannot keep finding the same thing with the research without trying to fix some of the infrastructure problems like data, management data sharing and definitely electronic data.

Professor Deirdre Heenan:

I would say that it all seems a bit depressing when you listen to this. It is hard to find something that is going to put a lift into your step, but we can look at countries across the world and say that when they have decided something is a priority and they have had an unrelenting focus on it, change is possible. In the North, we went from having the worst breast cancer outcomes to the best because we decided that this was not good enough. Unfortunately, we have slipped back because the focus stopped, but we can look at countries across the world which have said this is what they want to focus on and what is important to them, which is health outcomes and not just living longer but the quality of life for people living longer and how we ensure quality of life. Change can happen but it is about communicating with the public, getting them on board and saying that, in the end, this is something we all own and we all agree on. Of course it is difficult for politicians to talk about change in healthcare because it looks like turkeys voting for Christmas. Why would they? Sometimes we are so insular in the North, or even as an island, that we do not look beyond and say how, for example, Denmark went from having the worst cancer outcomes to being among the best. It was because there was a political consensus that the cancer outcomes were appalling and unacceptable. There was a cross-party consensus that a ten-year plan would be drawn up and, regardless of who was in power, that plan would happen. They have completely turned their outcomes around. Those are the types of things we should be presenting to people to say not to lose heart and not to feel that here we are again bemoaning a broken system. Instead, show them the possibilities of political will and economic change.

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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I thank both witnesses for their statements and their passion in this area. It comes across. To Professor Heenan directly, on the strand two piece you mentioned earlier and the North-South Ministerial Council, outside of those meetings, are you ultimately saying there is no other work taking place at all with regard to research or collaboration between the health systems in the two jurisdictions? Is there absolutely nothing happening at all or, at different levels, is it more informal?

Professor Deirdre Heenan:

There are projects happening. Professor Mark Lawler, who Deputy Conway-Walsh mentioned, and I are working together on an all-island cancer care system. That is being funded by Analysing and Research in Ireland North and South, ARINS. There are all sorts of those relatively small projects going on.

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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Not on the macro level.

Professor Deirdre Heenan:

Yes.

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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Okay. Between the NHS and the HSE, there is no-----

Professor Deirdre Heenan:

Not that I am aware of.

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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You also referred, in one of your answers to one of the committee members, to the fact there was a strategy published in the North with no reference at all to the southern health system. That is obviously a very bad place to start with regard to a strategy for a decade ahead or however long that strategy looks at.

Professor Deirdre Heenan:

It was a ten-year strategy.

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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When was that published?

Professor Deirdre Heenan:

That was published in 2021.

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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Okay. It was the height of the pandemic as well, I suppose, so there are learnings.

Professor Deirdre Heenan:

It came out a little bit later but the particularly disappointing part of that strategy, which was a mental health strategy, is that there are clear opportunities to work on an all-island basis because, as I said, depression is not different in Donegal from what it is in Derry. It does not really matter, in some cases, where those services are delivered and we can learn from each other about suicide in rural areas, for example. We are told, on the one hand, by some of our people in charge of health that all sorts of things are going on, but when you actually drill down to it, it goes back to my original point. There is a world of difference between co-operation, co-ordination and collaboration. I would really like that, in the near future, we get to collaboration.

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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Professor Matthews, you referred to the data issue. As you well know, there are issues with sharing data within the HSE, never mind with anybody else. That is a problem. I am sure it might be an issue in the North as well but we are looking at the digitisation of records and patient numbers, etc. I take the point - I think it was Professor Heenan who made it - around AI and how we can maybe look to leapfrog over the particular gulf that exists and say that where there is a will, there is a way and we can try to find a way of communicating between the two health jurisdictions.

With regard to making progress, you mentioned a strategic framework for an all-island health committee. Who would both of you envisage sitting on that in order to get proper collaboration between those two health systems, the Departments of Health and all the various facets that are involved?

Professor Deirdre Heenan:

That is a difficult question because I have been involved in healthcare transformation and the more actors you bring in, the less likely you have a chance of reaching any consensus.

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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You mentioned politics in your statement as well.

Professor Deirdre Heenan:

Politics, yes. When you think about it, the numbers of stakeholders are vast, not least, of course, the service users themselves. I would like to think that, as the first port of call, we would have a political agreement and then take it from there to wider stakeholders such as the unions and the professional bodies, etc., who will of course all have their own views. We have many professional bodies, but if you bring them all in a room together and hope for some sort of consensus going out the door, you might be disappointed, but if you brought together high-level politicians and policymakers to say this is possible, then there is something to sell to people, to say, "This is what you could have." From my perspective, that is how I imagine it could work.

Professor Anne Matthews:

On trying to scope out the benefits or potential benefits, people were talking about healthcare workforces being sucked one side of the Border and they might be going back the other side for other parts of the health system. Nobody wants that kind of scenario. Huge investment goes into training health professionals. There have been some collaborative arrangements North and South but quite few. It highlights the lack of capacity and workforce planning in both systems. There is a huge reliance on internationally trained nurses and midwives in the Republic, as members know. Each year, the amount of health professionals we are preparing for the workforce are, unfortunately, associated with emigration out of Ireland, and then we are trying to recruit in. We need to really focus on the shared problems and the big problems and whether there is potential for those to improve with collaboration. We keep coming back to it. Each system has very similar problems but also quite specific problems and we do not want everybody ending up feeling that things are getting more negative or even potentially getting worse for populations or healthcare workers within that system.

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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Even in your own statement, Professor Matthews, you referred to cross-Border healthcare and the successes we have seen already from collaboration and genuinely working together. There have been benefits to that, but you also alluded to the fact that there was a real focus on Border communities as opposed to that macro piece of genuine collaboration between both jurisdictions.

On the funding piece for an all-island health committee, with regard to the shared island initiative, a huge amount of money has gone into research, and you acknowledged that.

The health policy unit was mentioned. Would there not be scope there for both jurisdictions to contribute a certain amount to benefit, ultimately, some universal healthcare system as one unit? Would there not be a benefit to having co-funding?

Professor Deirdre Heenan:

Yes, of course. Alas, I fear that if you mention wanting money for anything out of a healthcare budget, you may get very short shrift.

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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You might be waiting.

Professor Deirdre Heenan:

You might be waiting. That is a political reality. Perhaps the shared island unit with universities North and South could say they are going to work together. On my more cynical days, I think that even if we came away with saying, “Here are the facts of the system as it sits at the moment”, that would be a step forward. We still hear on a regular basis, “Yes, but we get it free and down there you have to pay for it.” That is the truth of the matter, apparently, but it is not free. We pay tax and national insurance and we are having serious problems with access. Nor is the system in the South perfect. If we could start from a position of saying what the facts are and asking how we can improve outcomes based on these facts, and allow the general public and people who are interested in health and politicians and the wider policymakers to challenge myths or mistruths, we could go straight back and say that is actually not the case and we would have the evidence to show that they are misinformed.

Professor Anne Matthews:

The Centre for Health Policy and Management at Trinity College Dublin supported a lot of work during the implementation and development of Sláintecare. There is room for that kind of public sector university co-operation and non-competitive support for policy. Where there is expertise, where it is coming from should be transparent and that can support the policy system as well as all the in-house Department of Health and HSE policy expertise.

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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Before I bring Senator Black back in, given the discussion we have had and the questions around it, I invite both of our witnesses to furnish a note to the committee if they so wish. We are going to have our deliberations and this discussion around the healthcare system is going to continue for the next couple of weeks. I invite them to put some ideas forward if they wish.

Frances Black (Independent)
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My question relates to the report we hope to bring out after this. We will have many sessions on health over the next few months. I have found this session fascinating. It is almost like the witnesses have given us all the answers. It is not rocket science. It is just about bringing people together and getting people to sit down around the table to agree a strategy, basically, and then to implement that strategy. It is about getting people to sit down and talk about it.

I would love to know what both Professor Heenan and Professor Matthews would like to see in the report we are bringing out. What would they be happy with when they see the report? Could they give us three or four of the top recommendations they would like to see in it? Are there strong recommendations? I know they have spoken about them all morning but I just wanted to gather them for our own information for this report.

Professor Deirdre Heenan:

If I were putting together the recommendations, the first one would be leadership, so that it is not a system of “that is your responsibility” or “no, that is yours” and the public and everyone else is clear as to who is leading this project. By leadership, I mean a named individual. Our experience is that we are told it is "the department", that big black hole where we cannot find anyone who will actually take ownership of what is going on. With leadership comes accountability. People will buy into something if they see timelines, milestones and the funding and they are able to chart that this is not yet another strategy that gathers dust on the shelf or is abandoned because there is a change of political priority. Leadership is really important. We can look at and learn from somewhere like Denmark, where there is a ten-year plan with cross-party consensus. This will not happen overnight but people will buy into it if they think change will happen and within a given period of time.

The other issue in terms of the strategy is that we really think about data and how we use it. Professor Mark Lawler and I have just published a report on how we use data in cancer care and the importance of using data so that we can have a fully informed cancer strategy. Leadership and data are important, as is that wider view of knowledge sharing so that we learn from international examples. While it is great to have been invited here to discuss it, I would love to see people coming from other countries to say that these are problems that exist across the western world and this is what they did to address them. It gives people hope. Sometimes when we talk about health, people become so despondent that they just hope they do not become sick and that it does not happen to them or their family. That is no way to live, given the amount of money that we spend on this issue. It is about leadership, ambition, accountability and transparency. The members will hate this phrase, but we are all in this together. We are. It affects everyone.

Professor Anne Matthews:

Yes. I will not repeat those points because they are absolutely spot-on. It is about taking health in its broadest sense. The focus often has to be on healthcare services, specialist services or particular types of services but, as Professor Heenan said, having an ageing population is a good thing and it brings demands. If we are trying to keep people healthy and keep out of hospitals, the public health service is the primary service. The social determinants of health, such as housing and income, and the commercial determinants of health, such as those who market goods that damage health - all of those factors can be part of this. Sometimes we move between health and healthcare. Healthcare is one part of the response to keeping people healthy. As Professor Heenan said, there is nothing more important for everyone than their health and the health of the family and the investment in health. It is important to keep that central.

To go back to the data, it is not just about not having access to data; it is about whole definitional differences. Professor Heenan and colleagues are trying to do that for cancer care. What does that mean? Is it comparable data, rather than just exchanging data and, because they do not measure the same thing, abandoning them? Moving that ahead is a real project in itself.

Niall Blaney (Fianna Fail)
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To go back to the earlier question in relation to the money that was invested in the Magee campus in Derry. What impact, if any, will that have in the longer term for health services in Northern Ireland and the Border counties?

The second question is in relation to the North-South committee that was mentioned. I do not get how we would move forward to a policy on issues like this before the research is done. I just do not get that because for me the research drives this. That research is not done yet, so I think we need to hold back on setting up any committees. Moreover, as I mentioned earlier, there is the political piece in all of this. Health will not be decided until all the other Departments are ready as well. That will be a political piece, a bit like how the Good Friday Agreement was the one time on the island that we got people to say yes across the board. It may end up in a referendum. What is very clear today is that, while the combination is really good, there is a whole lot of work to be done here. We are not nearly at the committee level yet. We need to know the status quo, North and South, before we set down an agreement. Why would we sit down in a room with people when we do not know the status quo? We are not at that point yet. That has been made clear to me today. We need more research and we need to get it done sooner rather than later because that is the catalyst for how we move forward, the basis for moving forward and how we can improve and learn from each other, because I have no doubt there is a lot of learning to be done as well.

In relation to cancer services, we do not need to go to Denmark. I was in these Houses when Mary Harney brought in her strategy. Within five years, we had brought in the eight centres. That is why we have the service in the north west. We would have had to travel to Galway for services that are now 20 minutes up the road.

Some of these decisions are hard for politicians to take because they have real-life impact for their constituents.

In the context of all these things we talk about when it comes to sitting down and reaching agreement, we cannot agree on anything without having a budget to implement what we decide. We are rolling out primary care centres across the country at a fair rate. We are also rolling out step-down beds in the South. From what our witnesses said today, it is not happening in the North. A lot of money is required in that regard. The €2 billion in the shared island fund will not go very far, particularly as we have put tens of billions into the health service in the South over the past five years. There is no point in agreeing to anything until there is a budget in place. There is an awful lot to be agreed. I thank the witnesses for their input.

Professor Deirdre Heenan:

A free healthcare system is an avaricious user of resources. The more money put in, the system just seems to take more and more money. On the point that we cannot do anything in the short-term, I disagree. I am of the view that we can agree in principle. When we agree that collaboration is a principle that we want to explore fully, then we can move forward with an overarching vision and say, "We do not have all the evidence, but we do have evidence to know that we can create economies of scale on an island of this size." We absolutely know that. Professor Bengoa was quite amused in a strange way when he came to look at the healthcare system in the North. He said we had more pilots than Easy Jet, and he was right. For some reason, three pilots a year was our favourite number. He said that in his experience rapid research reviews could take place in 12 weeks. In 12 weeks, from start to finish, we can have a pretty good understanding of what is going on, if that is our aim and objective. It is a question of "How long is a piece of string?" If we have an agreed objective and ambition, change actually could happen fairly quickly.

I am sorry, I have twice ignored a question about Magee campus. We are delighted to see the funding for Magee campus. We know that when people study somewhere, they are much more likely to make their homes and start their families there. That is entirely what we want. We have regional disparities in the North. However, I would say from experience that people who are coming out qualified to work in the health service are looking around and that they think they will go to Australia or elsewhere. We do not even have pay parity with the rest of the UK. It is not an attractive proposition. We have to work to make sure that the jobs that are available to graduates are attractive enough to keep them and ensure that we benefit from their skills.

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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On behalf of the committee, I thank Professors Heenan and Matthews for their very engaging and frank look at the health service and the potential that exists. I thank them for their time. I also thank the members for their engagement.