We don’t know how Brexit is going to affect cross-border provision of health care, but one thing is certain: the current situation leaves plenty of room for improvement…

Paul Gosling recently posted about Professor Jim Dornan’s comments about the requirement for integrated provision of health care over the whole of Ireland. This article fills in some additional detail on hospital care, with special reference to the impact the lack of an integrated approach has had on the North West of Ireland.

While there are many admirable aspects of specialist health services on both sides of the Irish border, provision of health care in general is suboptimal for people in Ireland as a whole. This deficit is especially marked in remote rural areas, and even more so for those unfortunate enough to live close to the border. Indices of deprivation in rural border communities are generally high, and such indices include access to high-quality specialist health care.

There are many reasons for this, of which political division is only one. In the North the reasons include an intensely inward-looking and Belfast-based medical culture, a mixed economic system in hospitals introducing conflicts of interest for senior medical staff, and a Blairite reduction in the professional status and strategic influence of the medical profession, even more extreme in Northern Ireland than in the rest of the UK. The medical culture in the Republic, where senior staff are unofficially obliged to have spent some time in training in Britain or, especially, North America, is less inward-looking, but the conflict of interests (public versus private work) even more extreme, so that the focus of professionals is very strongly on the affluence of Dublin and, to a lesser extent, Cork and Galway (Limerick is now beginning to make some progress towards joining this oligarchy).

In the North, many specialists see no reason to work anywhere but Belfast. Traditionally patients have been expected to travel to the provincial capital for any kind of specialist care, and the realisation that this does not represent a fair or satisfactory situation has taken hold only recently. For its part, the Department of Health has consistently been influenced by short-term financial considerations, arguing, for instance, that the population of the West is insufficient to justify a locally-based vascular surgery service. In the Republic, exactly the same argument is advanced for lack of investment in specialist programmes in the North West. Even though these geographically-adjacent areas together would easily provide a critical mass to justify specialist services, patients are still obliged to travel long distances to Belfast, Dublin or Galway for care that, with a little bit of vision and investment, could easily be provided locally.

Political inertia and intellectual idleness on the part of the NI Department of Health mean that its strategic vision cannot extend beyond the border. This has led to anomalies such as establishment of an acute hospital in Enniskillen as part of the Western Trust. Enniskillen is, of course, remote from Derry both geographically and culturally, and pathways for provision of tertiary care unavailable locally remain confused. At the time of the decision to expand Enniskillen at the expense of Omagh (much better placed to develop an effective clinical network with Derry) the incumbent Minister for Health, Bairbre de Bruinn, made the fatuous comment that cross-border solutions could not be explored since “we don’t know what’s happening in Sligo”: a fabulous position for the one true all-Ireland party.

The opinions of senior specialists who see beyond the perceived economic and social benefits (for themselves) of keeping services concentrated in Belfast have been sidelined. Medical professionals are officially regarded by the Department of Health and healthcare managers as replaceable cyborgs (for instance, in contrast to England, no names of specialists can be found on Trust websites in Northern Ireland).

Promoting cross-border health care has remained an unrelenting struggle and, although Altnagelvin does now officially provide some selected specialist services for Donegal (including high-prestige but much-needed projects such as the Radiotherapy Unit), the persistence of a Belfast-centred culture means that recruitment and retention of high-quality staff remain problems. Hard-won collaboration in areas other than radiotherapy does exist: there is long-standing co-operation in renal medicine and dialysis vascular access, the CAWT faciomaxillary project has enabled facial and oral surgery services based in Derry to be delivered to Letterkenny and Sligo, and a contract for provision of emergency interventions for Letterkenny patients with heart disease in Altnagelvin represents a significant breakthrough.  Capacity is however limited, and many cases must still travel to Galway (a ten-hour ambulance round trip, typically in the course of a single day, with an uncomfortable medical procedure sandwiched between). Many patients with joint disease in Donegal wonder why they must travel to Manorhamilton, hardly the hub of an effective public transport network, for outpatient rheumatology assessment and treatment.

Other obstacles include a possible local perception in Donegal that sending patients to Derry will result in reduced importance and influence for Letterkenny, diminishing the chances of future investment further still.

Improvement in recruitment and retention (and thus capacity) in Derry could be addressed in two ways: triggering existing structures for provision of incentives (but the Department and its executives locally have consistently refused to do this), and establishment of a local medical school. Almost two decades ago discussions about a bifocal graduate medical school in Limerick and Derry reached an advanced stage, but any cross-border initiative was beyond the DoH’s myopic strategic vision and the issue was quietly dropped; Limerick proceeded alone, with phenomenal success. More recently, another initiative for a graduate medical school on the Magee campus has almost reached completion with an opening date fixed for September coming. Frustratingly, though, progress has been halted by the hiatus in devolved government.

Despite recent advances, the Irish border remains one of the least permeable in Europe to health care; cross-border provision between Belgium and the Netherlands, for instance, is an entirely routine affair. Yet the universal right to high-quality health care is a social and not a political issue, and whatever happens with Brexit, the people of the fourth city of this island and its hinterland (Donegal as well as Counties Londonderry and Tyrone) deserve better. Similarly, collaborative initiatives to identify ways of providing high quality care for residents of Sligo, Leitrim, Cavan and Fermanagh (Enniskillen being the most central geographical focus) and for those in South Armagh, Newry and Mourne, Monaghan and northern Louth (perhaps based in Newry and/or Dundalk) are urgently required. It should no longer be acceptable to fob off residents of the border region with hollow economic and political arguments.

Peter Garrett is an independent writer and physician. Now working with Syrian refugees in the Lebanon, he was previously a Consultant Physician and Clinical Lead for Metabolic Medicine with the Western Trust, and chaired the EU-funded CAWT renal IT project, securing a single clinical information system for renal medicine extending across the whole of Ireland.

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