99.Reciprocal healthcare arrangements on the island of Ireland date back to agreements reached before the Republic of Ireland and the UK joined the EU. Because these arrangements function on either side of the UK’s only land border with another EU Member State, Brexit will pose specific problems to healthcare provision that deserve to be analysed separately from the other concerns that our witnesses raised.
100.Professor Martin McKee noted that “many of the [reciprocal healthcare arrangements between the UK and the Republic of Ireland] take place on a purely bilateral basis, although they are underpinned, ultimately, by European Union law.” Such arrangements include bilateral cooperation under the Common Travel Agreement (CTA), and Strand Two of the 1998 Belfast/Good Friday Agreement. For Damien McCallion, Director-General at Co-operation and Working Together (CAWT), a partnership between the Northern Irish health services and the border counties of the Republic of Ireland, there were probably “as many people availing themselves of directly agreed services [i.e. bilateral arrangements]” as used EU reciprocal healthcare schemes such as EHIC, S1, S2 and the Patients’ Rights Directive.
101.Mr McCallion explained that healthcare cooperation on the island of Ireland covered a wide range of services, including emergency care, travelling from one jurisdiction to another to access health services, the provision of direct services, and cooperation on new initiatives.
102.Various bilateral healthcare schemes and initiatives are run by CAWT, whose board is comprised of Chief Executives of Health and Social Care on both sides of the border. It receives funding not just from the UK and Ireland but also from the EU, primarily via the EU regional development INTERREG programme. Damien McCallion described EU funding as “invaluable” in stimulating and encouraging cooperation. European funding had supported cooperation in a range of areas, including “acute, mental health, disability, older people, primary care and emergency services”.
103.The border area has a dispersed population of around 2 million, and CAWT’s work focuses on “very rural” and disadvantaged areas. Bernie McCrory, Chief Officer at CAWT, underlined that “from a staffing point of view … quite often, you would not be able to attract a consultant in a particular speciality if you did not have the population. The combined population allows us to provide services that we would not ordinarily have if we were doing it on a back-to-back basis.” The Royal College of Physicians of Edinburgh also noted that cross-border health programmes on the island of Ireland “serve communities on both sides of the Irish border, thereby reaching sufficient patients to secure the economies of scale necessary to justify provision.” Joint services include oral and maxillofacial services; a radiotherapy centre opened in November 2016 in the Western Trust at Altnagelvin Hospital was “co-funded and co-planned by both jurisdictions”.
104.Ms McCrory told us how cooperation in ear, nose and throat (ENT) services had led to improved access to healthcare to people living in the border areas:
“Children were waiting for maybe four years for their first appointment if they had hearing difficulties, with all of the problems that that would have thrown up education-wise and so on. There was a very robust ENT service in the Southern Trust in Northern Ireland where we had four ENT surgeons working on a rota. The EU money allowed us to employ two more ENT surgeons. The surgeons rotated into the south of Ireland, into Monaghan, where they did out-patient and day-case work. Then the patients travelled to Northern Ireland, to Craigavon and Daisy Hill Hospitals in the Southern Trust, to receive more complex surgeries that were not possible in a small rural hospital … [In 2016] 155 patients travelled from the south of Ireland to Northern Ireland for complex surgery, but the consultants who travelled down to the Republic saw over 2,000 patients in both out-patient and day-case procedures.”
105.Damien McCallion explained how patients also travelled across the border, north or south, to access emergency health services. Although the numbers taking advantage of this arrangement were small, the need was critical. Dr Anthony Soares, from the Centre for Cross Border Studies, stressed that “one of the crucial issues” arising from Brexit was the risk of “exacerbating the overall peripherality of the border regions”.
106.Witnesses described a range of real-life consequences for cross-border healthcare in the event of changes to existing reciprocal arrangements. Professor Martin McKee highlighted the many cross-border workers who would potentially be affected (there are around 102 million border crossings per year). Professor McHale expressed concern about potential impediments to cross-border movements, which would present a “practical problem”, because “certain healthcare services are delivered on one side of the border that are not [available] on the other”.
107.The Royal College of Physicians of Edinburgh warned that, because cross-border collaboration in health was an integral part of the peace process, Northern Ireland could “experience substantial disruption in service delivery” due to Brexit. Professor McKee noted that “when you get into the detail … all sorts of things come up, like ambulances going across borders carrying morphine to treat somebody with a heart attack. That, for example would be illegal, potentially, outside the European Union … There are all sorts of issues that relate to free movement of services and people that could be complicated.”
108.Ms McCrory highlighted “many examples” where “patients’ lives had been saved because of free and open access” of emergency services across the border. She contrasted this situation with a time when “ambulances would drive up from one side of the border, [while an] ambulance on the other side of the border would meet them, and the patient would transfer” into the other ambulance.
Strand Two of the Belfast/Good Friday Agreement established the North/South Ministerial Council. The North/South Ministerial Council has a joint secretariat staffed by the civil service of the two jurisdictions.
The Council brings together those with executive responsibilities in Northern Ireland and the Irish Government, to develop consultation, cooperation and action within the island of Ireland—including through implementation on an all-island and cross-border basis—on matters of mutual interest within the competence of the Administrations, North and South.
Northern Ireland is represented by the First Minister, Deputy First Minister and any relevant Ministers, and the Irish Government by the Taoiseach and relevant Ministers.
109.Dr Soares described cross-border healthcare as “one of the success stories” of the Belfast/Good Friday Agreement. It was not a question of whether to continue cooperation, but “how we undertake cooperation in future”. He gave compelling evidence on the critical need not to let Brexit undermine the Agreement:
“The UK Government, the Commission and the various institutions in Europe stress repeatedly that the withdrawal agreement cannot undermine the 1998 Agreement in any of its parts … ‘any of its parts’ means all three strands. It means the totality of relationships, the commerce and human flows that occur on a north-south and east-west basis within and between these islands. That is what must be safeguarded.”
110.This bears out the conclusion in our December 2016 report on Brexit: UK-Irish Relations, where we stated that cross-border healthcare on the island of Ireland was a “demonstrable success story”, and that it was “vital that these and future projects are not placed in jeopardy by Brexit”.
111.Dr Soares warned that maintaining healthcare arrangements would mean resolving “a wide range of issues”, including, but not limited to, “the timely movement across the border of ambulances, patients and healthcare professionals, and, perhaps most important, the avoidance of divergence in terms of relevant policies, regulations and standards.” He also highlighted the significance of “continued reciprocal recognition of professional qualifications”. He expressed particular concern about the Government’s desire to leave both the single market and the customs union, which would make it “rather more difficult” to maintain the current ease of cooperation that takes place in the border area.
112.The importance of ensuring continued reciprocal healthcare arrangements was put in stark terms by Bernie McCrory of CAWT, who warned us that:
“The patients, the citizens themselves, will not be very happy if there is no agreement. It is fine if you have never had those services, but if a service that you have become used to is removed, I do not think the citizens would be happy about that. It is very natural for them to cross the border and receive services and I do not think they would accept anything less.”
113.Like the EU’s freedom of movement provisions, the Common Travel Area (CTA) also underpins reciprocal healthcare agreements between Northern Ireland and the Republic of Ireland. The CTA pre-dates EU membership but is acknowledged in the EU treaties. It is an agreement permitting freedom of movement between the UK, the Republic of Ireland, the Crown Dependencies of Jersey and Guernsey, and the Isle of Man. The Department of Health and Social Care wrote that under the CTA arrangements, Irish citizens resident in the CTA enjoyed “access to UK health services”, including “emergency, routine and planned access to health services”.
114.Dr Soares stressed the difficulty of maintaining the CTA post-Brexit on the basis that “Ireland will continue to be an EU member state”, meaning that the “degree to which it can reciprocate some arrangements might be constrained”.
115.Both the CTA and the 1998 Belfast/Good Friday Agreement will remain in place after the UK leaves the EU. The Joint Report recognised “that the UK and Ireland may continue to make arrangements between themselves relating to the movement of persons between their territories (Common Travel Area), while fully respecting the rights of natural persons conferred by Union Law.” With regard to the Belfast/Good Friday Agreement, the Joint Report noted that both parties agreed that it “must be protected in all its parts”.
116.The Joint Report also reaffirmed commitments to INTERREG and other funding programmes for the current EU multi-annual financial framework. One of the four objectives of the INTERREG funding is cross-border health and social care (the programme covers the west of Scotland and the north of the island of Ireland).
117.Speaking prior to the publication of the Joint Report, Dr Soares was cautious about the ongoing negotiations, noting that progress had yet to be made in areas such as “the ability of health authorities to procure services and goods on a cross-border basis”. Damien McCallion saw some room for optimism: he was “positive” that solutions could be found, and noted the commitment from both Governments to the Belfast/Good Friday Agreement. He flagged four areas that would need to be considered in order to find a solution to potential future reciprocal healthcare problems: workforce; cross-border services; procurement and regulation on medicines, drugs and medical devices; and EU funding.
118.After the Joint Report was published, Cooperation and Working Together was concerned that it did not “provide any detail on how a ‘soft’/open border will be achieved”, and that, while the Report covered some aspects of reciprocal healthcare, “there were many other aspects of healthcare that remain unclear as to future status and operation”. They wrote that “it would be important that patients, staff and ambulances can continue to cross the border unhindered”.
119.Dr Soares’s organisation, the Centre for Cross Border Studies, pointed out that the Joint Report could lead to a “differentiated set of EU entitlements within Northern Ireland”, since residents of Northern Ireland with Irish citizenship would, unless there were a future agreement, be entitled to healthcare in the Republic of Ireland whereas those with British citizenship would not. Lord O’Shaughnessy disputed this point, however, suggesting that rights to access healthcare would be protected by the Joint Report’s aim to safeguard rights afforded by the Common Travel Area. Lord O’Shaughnessy also told us that the Government was “absolutely engaged” in working with counterparts in the Republic of Ireland on the matter of reciprocal healthcare, underlining that “we are very clear about wanting to respect the continuity of the common travel area”.
120.Despite the Minister’s optimism, the Joint Report provided little detail about how the EU and UK would manage the land border on the island of Ireland. Its various commitments will need to be turned into workable, practical solutions, and enshrined in legal text. The Joint Report states that the first aim is to protect north-south cooperation through “the overall EU-UK relationship”; failing this, the UK will propose “specific solutions” to address the situation in the island of Ireland. If that approach fails, there is a UK commitment to “full alignment” with those rules of the internal market and the customs union that support north-south cooperation, the all-island economy and the 1998 Agreement. The Government has yet to explain in detail what any of these options might mean in practice, but to meet our witnesses’ concerns, it is clear that the Government will need to secure the full range of reciprocal healthcare arrangements that we have described.
121.We note the success of cross-border collaboration on healthcare between Northern Ireland and the Republic of Ireland, particularly in radiotherapy and Ear, Nose and Throat services. We also note that ambulances are currently able to travel freely across the border, that medical professionals from one country can work in the other, and that patients can easily cross the border to access healthcare.
122.We welcome the assurances contained in the Joint Report about the importance of maintaining freedom of movement under the Common Travel Area and cooperation under the 1998 Belfast/Good Friday Agreement. Regardless of the other arguements against a hard border, any such barrier would be highly detrimental to healthcare for patients on both sides of the border, including children and other vulnerable patients.
123.We urge the Government to avoid such a hard border for patients and the health professionals who treat them, and to secure continued access under the Common Travel Area to emergency, routine and planned treatment.
124.Given the key role that bilateral and EU-level cooperation has played in improving access to healthcare in the border areas, we call on both sides of the negotiations to treat healthcare as a priority in the final settlement of issues relating to the island of Ireland.
145 Written evidence from the Royal College of Physicians of Edinburgh ()
152 Written evidence from the Royal College of Physicians of Edinburgh ()
157 European Union Committee, (6th Report, Session 2016–17, HL Paper 76)
160 Written evidence from the Department of Health and Social Care ()
162 Home Office and Department for Exiting the European Union, Joint technical note on the comparison of EU-UK positions on citizens’ rights (December 2017), para 54: [accessed 20 March 2018]
163 European Commission and HM Government, Joint Report on progress during phase 1 of negotiations under Article 50 TEU on the UK’s orderly withdrawal from the EU, (8 December 2017): [accessed 20 March 2018]
167 Supplementary written evidence from CAWT ()
168 Supplementary written evidence from the Centre for Cross Border Studies ()
170 The draft Withdrawal Agreement includes a Protocol on Ireland/Northern Ireland that forms the Commission’s interpretation of the undertaking in paragraph 40 of December’s Joint Report. This paragraph stated that in the absence of agreed solutions, “the United Kingdom will maintain full alignment with those rules of the Internal Market and the Customs Union which, now or in the future, support North-South cooperation, the all island economy and the protection of the 1998 Agreement.” European Commission and HM Government, Joint Report on progress during phase 1 of negotiations under Article 50 TEU on the UK’s orderly withdrawal from the EU, (8 December 2017): [accessed 20 March 2018]. European Commission and HM Government, Draft Agreement on the withdrawal of the United Kingdom of Great Britain and Northern Ireland from the European Union and the European Atomic Energy Community (19 March 2018): [accessed 20 March 2018]