THE BORDER HAS figured heavily in debates about Covid-19 as some experts call for an all-island approach to tackling the pandemic.
Yet the virus has revealed the fragmented nature of cross-border healthcare in Ireland, even as Brexit threatens to upend years of tentative integration.
As Covid-19 rates rose in Northern Ireland to become among the highest in Europe, health officials and politicians in the south looked on in alarm.
And while the Irish government stressed that it “wasn’t in the business” of erecting borders, real fears remain about coronavirus hotspots in Donegal, Cavan and Monaghan.
The Level 4 restrictions imposed in the three counties have largely harmonised restrictions across Ulster – a remarkable acceleration of healthcare co-operation between the two parts of the island.
For many, such an approach is long overdue – even if cross-border co-operation to suppress the virus remains lacklustre.
But the fresh measures to deal with the second wave of Covid-19 reveal the largely ad hoc nature of cross-border care that has developed in the last two decades.
“It’s a bit like Brexit,” Sinn Féin’s health spokesperson David Cullinane told TheJournal.ie.
“It’s brought into focus the folly of partition.”
Beyond Covid-19, his party believes that current levels of integration need to increase.
“We want to see an integrated hospital waiting list – there is no reason that can’t be done on an all-island basis.”
Cullinane blames a lack of “political will” for the sluggish approach to the issue.
“It’s down to whether we’re going to make it happen and make it a reality,” he said.
That reality has sometimes seemed to be getting closer with each passing year.
In May 2017, the Prince of Wales opened the North West Cancer Care centre Altnagelvin Hospital.
The Derry centre, which opened after years of funding wrangles, treats cancer patients from Donegal – saving them a three-to-four hour journey to Galway or Dublin.
Most significant of all is that €19 million – or about a quarter of the total bill – for the centre came from the Irish government. Our name might not be on the wall, one doctor told TheJournal.ie, but the Department of Health owns part of a hospital in Derry.
So far, at least 400 people from Ireland have received care in the centre.
There have been other cross-border successes too.
Cardiac care, where time is of the essence, was an obvious first step.
Since May 2016, patients having a heart attack in Donegal can be rushed to Altnagelvin Hospital in Derry – an arrangement that the HSE estimates saves 70 lives every year. Paediatrics, especially in the area of cardaic care, also has an all-island dimension.
‘Art of the possible’
In the middle of all this stands the Co-operation and Working Together (CAWT) partnership.
Headed up by Damien McCallion, a HSE national director, the body emerged from the optimism of the peace process in 1992 and now exists to further collaboration on both sides of the border.
Backed by generous EU funding – in 2017, over €26 million was awarded to support cross-border projects up until 2022 - CAWT has acted as a catalyst for forging cross-border links.
Speaking at an online conference at the end of last month, McCallion described the organisation’s work as the “art of the possible”.
CAWT has had its successes – notably two out-of-hours GP services that provides cross-border care in the Inishowen-Derry area and in the South Armagh-Castleblaney region.
There have been a range of smaller projects too focused on mental health and community care, financially backed largely by the EU albeit with some support from the Irish government and the NI Executive.
The organisation’s focus stretches far and wide.
In 2015, CAWT helped facilitate a seminar on the Ebola response on at the Curragh that saw medical practitioners hearing from the British army medical corps.
Yet with staffing and support largely dependent the goodwill of the Irish and Northern Irish administrations, sceptics say that while useful to a point, CAWT’s piecemeal approach is best only at keeping the spirit of co-operation alive.
Supporters stress that the logic of cross-border care isn’t just constitutional. Across Europe, residents of border areas often have limited access to doctors and treatments. That story is much the same in Ireland.
But aside from a slightly cryptic reference to strengthening “north-south health links” in the Programme for Government, there is little indication of which areas are next for further co-operation.
Brexit
Observers are united in the view that cross-border care will be impacted by Brexit. Yet the extent of that impact remains debated weeks out from the UK’s exit from the EU amid the uncertainty of a deal.
The SDLP’s Matthew O’Toole told TheJournal.ie that the pandemic has highlighted the need for better all-island collaboration.
“There shouldn’t be any constitutional angst about admitting that being on an island creates unavoidable imperatives around disease control and public health,” he said.
He believes that Brexit has created a “multiplicity of challenges”.
“Loads of stuff is currently covered by common EU frameworks. It won’t be at the beginning of next year and we don’t know what’s going to replace it,” he said.
The fact that Northern Ireland will have left the EU creates a range of administrative headaches.
O’Toole said: “It’s not the EU that mandated north-west cancer care collaboration. They didn’t cook it up in Brussels. It’s just that the legalities of it have been smoothed out by having the common basis of EU membership.”
These concerns have long been flagged. In 2018, CAWT warned:
It is evident that Brexit poses challenges to both formal and informal working relationships and arrangements which characterise cross border health and social care activity. In the meantime, cross border health and social care work will continue as normal, but with a sense that the landscape may change in coming months and years.
“From a health and social care perspective, it would be important that patients, staff and ambulances can continue to cross the border unhindered. It would also be important that there is continued mutual recognition of qualifications and mobility of health and social care staff,” the body said.
The same questions are still being asked today.
A particularly fiery debate took place in the Dáil this month as Cork and Kerry TDs questioned Taoiseach Micheál Martin over whether the EU cross-border healthcare directive could continue after 2020 – an arrangement that has seen hundreds of people travel north for procedures like cataract operations to avoid lengthy Irish waiting lists.
“Does the Deputy understand that Brexit is happening?” Martin asked Cork TD Michael Collins at one point.
He said that a similar cross-border scheme is “currently being considered and discussed with the UK authorities”.
And while the Irish government has committed to forging the bilateral links necessary to keep such programmes afloat, some worry that while some practical arrangements may survive into the future, there’s a more fundamental threat to the willingness to work together.
Donegal GP Denis McCauley thinks that the pandemic has “brought fresh impetus to cross-border initiatives”.
The logic of such arrangements are irrefutable.
“From a life-saving point of view, there are immediate benefits,” he said.
But that momentum, which might ultimately lead to better healthcare for border counties, is threatened by Brexit.
“Once Covid crisis is over and Brexit begins, an inadvertent cold war could start again,” McCauley said.
The UK’s exit from the EU threatens to disrupt the goodwill from which cross-border initiatives grow.
“We did it because it’s a good idea. If we’re not doing everything together, the initial lightbulb moment might not flash,” he adds.
Simply put, co-operation is hard to achieve when two countries are looking in different directions.
Brexit is not the only problem. Ireland’s mixed health system, with elements of public and private care, is vastly different from the NHS-run system in Northern Ireland. The two bureaucracies may be able to align further, but anything that looks like an all-island merger would be practically impossible without major reforms.
“There is an obvious problem because of the different health system. But that may change in the Republic,” said Martin McKee, professor of European public health at the London School of Hygiene and Tropical Medicine.
Things are unpredictable, he says, but one thing is clear as both sides deal with the looming constitutional issues that such talk raises: “It won’t be health that decides the big political questions.”
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