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Fighting the scourge, two ways or one?

Deirdre Heenan reflects on cross-border cooperation in health in Ireland.

It has been widely claimed that the failure to adopt an all-island approach to the Covid-19 crisis presents a major threat to health and well-being on this island. From the earliest days of this pandemic the absence of an overall strategic approach has been identified as a major obstacle to dealing effectively with the global emergency. It has been asserted ad nauseam that ‘this virus doesn’t respect borders’ and ‘the disease does not discriminate’, but without meaningful political action. We share a single island, one epidemiological unit and therefore need coherence. Despite the broad acceptance that thinking in terms of narrow political allegiances or identities would only prolong this crisis and deepen the impact on every community, cooperation to date has been woefully inadequate. Both governments have continued to plough their own furrow with little more than lip service paid to working collectively to fight this common scourge.

In March, the first minister slammed the taoiseach for lack of cooperation with Stormont over coronavirus. She claimed that he did not brief the Northern Executive before announcing school closures and Belfast officials learnt of the new regulations through the media. The Irish government pointed the finger of blame at the Executive, suggesting some were more interested in slavishly replicating Westminster policy, rather than developing a bespoke all-island response. In April the signing of a Memorandum of Understanding between the north and the south was broadly welcomed and viewed as a significant step in the right direction. In the face of this existential threat, it appeared that constitutional politics would rightly play second fiddle to public health considerations. The Memorandum acknowledged a compelling case for strong cooperation, including information-sharing and, where appropriate, a common approach. In reality, this agreement appears to, at best, have made a marginal difference. Practically, it has translated to regular Zoom calls between the Chief Medical Officers and some sharing of data. Window dressing and a far cry from the integrated, single-epidemiological coherent response to Foot and Mouth Disease (affecting livestock). Substantial differences in regulations, restrictions, data analysis and messaging pose practical challenges, cause confusion and are completely illogical on an island the size of Ireland.

This debate on the divergent responses to coronavirus has pushed the wider issue of north-south cooperation in health and social care into the spotlight. Providing healthcare services commands the largest allocation of public funding on both sides of the Irish border and there are persistent concerns over the efficiency and effectiveness of these systems. Theoretically closer cooperation could deliver economies of scale, value for money, opportunities for clinical specialisation and facilitate the sharing of knowledge. Over the past two decades health has been identified as a key area for increased cross-border working. To date though, with the notable exceptions of the All-Island Congenital Heart Disease Network and the North West Cancer Centre at Altnagelvin, the approach has been minimalist and often project specific. Joint EU membership enabled cross-border healthcare activity in Ireland, Co-operation and Working Together (CAWT) was established in 1992, its mission ‘to improve the health and wellbeing of the border populations by working across boundaries and jurisdictions’. Through this vehicle significant work has been done to enhance cross-border collaboration in health service delivery. Indisputable benefits have been achieved, providing access to services for communities within the border region, largely on a south-to-north basis. However, in most instances in these initiatives funding has been time-limited, and services have not been mainstreamed.

The North South Ministerial Council (NSMC) established under the Good Friday Agreement agreed six formal areas of cooperation, for which common policies and approaches are agreed but implemented separately in each jurisdiction, including in health and accidents and planning for major emergencies. In response to the health emergency, the 24th plenary meeting NSMC was held in July 2020, the first since before the collapse of Stormont power-sharing in 2016. It gave a commitment to do ‘everything possible’ in coordination and collaboration to tackle the virus. It was agreed that an early meeting of the health sectoral group would be convened to review responses to the pandemic. At their meeting on 2 October, the sectoral group agreed to review their existing health work programme. No time frame nor objectives were agreed for this review. The health minister is legally required to provide a statement to the Assembly on this meeting, to update on progress and allow for scrutiny. To date no statement has been presented, nor is one scheduled in the Assembly business timetable. If this is how a priority is treated, one wonders how the government treats things that they don’t view as important. Just weeks ago, the deputy first minister suggested that ramping up cross-border health provision could help to reduce Northern Ireland’s ‘dire’ waiting lists. Whilst there can be no dispute that they are dire, this is empty rhetoric. Given that the Executive has yet to formulate a strategy for dealing with waiting lists which are currently 100 times that of England, this is a useful deflection. The regular and repeated calls for further collaboration and cooperation have not been accompanied by any detailed plans, cost-benefit analysis, feasibility studies or robust data to support an all-island approach.

Meaningful change in the all-island health agenda will not happen without a major policy imperative. There is an absence of any agreed strategic framework for health and social care systems to underpin cross-border cooperation, a situation exacerbated by the apparent lack of political will north and south to commit to cross-border cooperation on an agreed plan of work. The pandemic has raised difficult questions about the extent to which both governments have lived up to commitments to developing cooperation across the island. The new €500 million Shared Island Unit provides a unique opportunity to address the long-standing issues around cooperation in health and reflect on the Covid-19 response. A comprehensive programme of research and development could provide the evidence to identify interventions that would be to the ultimate benefit of all of the citizens on this island. Given the similar social, economic and political pressures faced by both health care systems coupled with a pandemic that has steamrolled the country, it is an opportunity that we can ill afford to miss.

Read the full article, ‘Cross-Border Cooperation Health in Ireland‘, as it appears in our journal Irish Studies in International Affairs.