Cross-border Healthcare

Opposition Business – in the Northern Ireland Assembly at 2:45 pm on 18 June 2024.

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Debate resumed on motion:

That this Assembly acknowledges the daunting challenges facing our health service; laments that Northern Ireland has fallen behind the Republic of Ireland and the rest of these isles on several healthcare outcomes; understands that a solution to our healthcare challenges will not come solely through increased funding, but also through reform of our services; recognises that a key element of this will be further collaboration with the healthcare service in the Republic of Ireland; acknowledges that certain bespoke specialist services, in particular perinatal and paediatric post-mortem services, which are currently not available in Northern Ireland, could be delivered more efficiently and compassionately on an all-island basis; calls on the Minister of Health to work with the Irish Minister for Health to identify how the two jurisdictions can work together to reduce waiting lists, harmonise healthcare pay rates, and deliver bespoke specialist services on an all-Ireland basis.

Photo of Carál Ní Chuilín Carál Ní Chuilín Sinn Féin

The Minister of Health, Mr Mike Nesbitt, will now respond to the debate. Minister, you have 15 minutes.

Photo of Mike Nesbitt Mike Nesbitt UUP

Thank you, Principal Deputy Speaker. Perhaps I should begin by repeating something that I said in yesterday's debate: I have no ideological or political objection to further cooperation with health authorities in the Republic. I have no issue with exploring opportunities for reasonable cooperation on health, and, indeed, I look forward to my first engagement with my counterpart, Minister Stephen Donnelly. I understand that I am due to meet him next week.

When it comes to health and well-being, doing what is right will always be my main priority. My mantra, of course, is for better outcomes. Given that health services in countries across Europe are under pressure to varying degrees, it makes sense that we work together with our nearest neighbour in a mutually beneficial way to improve outcomes for everybody. There is, of course, a long-standing principle of cooperation and collaboration with health services in the Republic of Ireland, where it has been demonstrated that it is safe, deliverable and beneficial to patients and their families in both jurisdictions. Indeed, we have seen very good examples of that in the all-island congenital heart disease network, a single service for children and young people across the island of Ireland; and in the North West Cancer Centre, which I shall return to later.

Specialist paediatric services, which are referenced in the motion, are, by their nature, relatively low-volume, high-complexity services, and many already operate on the basis of clinical cooperation with other specialist centres in both Great Britain and Ireland. For example, paediatric gastroenterology has on-call support with the South and referral pathways to Great Britain centres. Where there are further viable opportunities for cross-border collaboration in vulnerable or specialist services, these could and should be fully explored within available resources. Therefore, it is not so much a question of cooperation as of capacity. The child health partnership programme board, which was established to provide strategic direction for the child health partnership may consider vulnerable and specialist paediatrics as part of the future work plan of that partnership.

Regarding paediatric and perinatal post-mortem services, I will say, first, that I, of course, fully sympathise with the devastating loss that many people and families have experienced, and that includes at least one Member of the House. Therefore, I recognise the importance to them of having the causes of a pregnancy loss or of a child's death examined and understood in a professional and empathetic manner. Mr McGrath talked of two words: "efficiency" and "compassion"; I would add "professionalism" and "empathy". Paediatric and perinatal post-mortem services have been provided to Northern Ireland by Alder Hey Children’s NHS Foundation Trust in Liverpool since 3 January 2019. That is when the service in Belfast became unsustainable, following the resignation of the sole paediatric pathologist. Families accessing the service receive all the clinical advice, psychological support and aftercare that they require. I understand that the uptake of the service is comparable with the uptake when it was based in Belfast.

That said, I certainly do not disagree that a service based on the island of Ireland could be somewhat easier for families who find themselves in that situation. However, until a full assessment of feasibility has been carried out, it is not possible to say that an all-island paediatric pathology service would be clinically or economically viable. My Department remains committed to progressing scoping work with the Department of Health in Ireland to explore the feasibility of an all-island approach to those services. Progressing the feasibility assessment will require the commitment of Governments in both jurisdictions in order to proceed.

Photo of Justin McNulty Justin McNulty Social Democratic and Labour Party

I thank the Minister for giving way. Minister, I met your counterpart in the South on various occasions, and he is openly willing to explore cross-border opportunities. He suggested that the impetus must come from the Northern Minister. All-island healthcare makes sense when it comes to sharing resources and expertise, tackling waiting lists and ensuring better health outcomes and efficiencies. The cross-border healthcare directive needs to be reinstated. Centres of excellence make sense. Does the Minister agree that Daisy Hill Hospital is primely positioned to become a centre of excellence and that it should be a hub hospital serving its natural hinterlands of the counties of Armagh, Down, Monaghan, Louth, Cavan and, potentially, even Meath? What does the Minister think?

Photo of Mike Nesbitt Mike Nesbitt UUP

I think that the Member has made a very good constituency pitch ahead of the next Assembly election. I will turn to the configuration of hospitals in the weeks ahead.

Returning to the children's services that I was talking about, I assure Members that significant efforts were made to retain the service in Northern Ireland prior to 2019. However, the provision of perinatal and paediatric pathology services is under considerable pressure across the UK and, indeed, globally, due to a shortage of paediatric pathologists. Our first priority must be to ensure that Northern Ireland maintains access to high-quality, reliable and timely pathology services at Alder Hey, at least in the interim, so that bereaved parents can continue to receive pathology reports as quickly as possible. I am reassured, on the basis of the feedback received, that parents have felt supported by the interim service provided at Alder Hey.

Photo of Liz Kimmins Liz Kimmins Sinn Féin

I thank the Minister for giving way while talking about this important topic. He will know that, a number of weeks ago, Sinn Féin tabled a motion on baby loss certificates, which incorporated a discussion of this issue. I had hoped to be able to raise this point with the DUP Member who spoke on it earlier. For many families — I know many who have experienced this — having to send their baby on a plane to Liverpool is more traumatic. In the absence of being able to recruit a paediatric pathologist in the North, does the Minister agree that it makes sense to have access to that service on this island, whether in Dublin or elsewhere, to make it easier for families going through that really horrible experience?

Photo of Mike Nesbitt Mike Nesbitt UUP

I thank the Chair of the Health Committee for her intervention. Would I like the service to be available locally? Yes, of course. Is it currently possible to do that? No, it is not, so what are the best alternatives? The Chair makes a compelling point about not having to get on a plane and fly. The scoping exercise will be conducted.

Mr Robinson made some points about the unacceptability of the service not being available in Northern Ireland. I assure him that I have taken advice from the Belfast Health and Social Care Trust, and it appears that there is a move nationally to centralise services by having fewer centres, which is not the direction of travel that the Member wants to see, because of the international shortage of pathologists with a specialist interest in paediatrics. Alder Hey is one of those new centres. There are currently no trainees in the pipeline, and any internationally recruited postholders are likely to go to those national centres.

I remind the Member that the service was stopped because of the pathologist's retirement. I also suggest that, perhaps, it is the sort of job that people should not do for life. For example, when I was on the Policing Board, there were police officers whose job was to look through extensive files of images of child abuse and child sexual abuse. That is not something that any individual should do for a 30- or 40-year career, and that is part of the problem with paediatric pathology services.

Mr Robinson also talked about the Health budget. I gently say to him that there was no mention of assessed need in his remarks. The Minister of Finance successfully argued with the Treasury that our block grant should be based not on population but on need, yet it seems that, when it comes to the Health budget, need is forgotten. It is a big quantum, but it is there for a reason.

I mentioned the North West Cancer Centre. Based at Altnagelvin Hospital, it serves the whole north-west corner of the island, but it is not the only example of such cross-border cooperation on cancer care. The all-island cancer consortium — the Ireland-Northern Ireland-National Cancer Institute Cancer Consortium — was established in 1999, following the signing of the Good Friday Agreement. The consortium is credited with saving lives and enhancing the quality of life for many cancer survivors by supporting work on cancer clinical trials infrastructure and an all-island joint research project, providing upskilling and training opportunities for scientists, doctors and allied health professionals. Meanwhile, cancer policy units in both Health Departments have had ongoing engagement over the past couple of years on identifying potential projects to submit as Shared Island Fund applications. Such projects include the use of artificial intelligence in screening applications, development of virtual rapid diagnostic clinics, further development of services at the North West Cancer Centre and development of community-based support services.

The motion highlights healthcare pay rates. Let me say at the outset that there is no easy fix. Although I acknowledge that pay rates are an integral element of the functioning and efficiency of healthcare services, I must point out that rates of pay across Health and Social Care (HSC) are linked to Agenda for Change terms and conditions. There is an established and valued policy of pay parity with England for Agenda for Change workers. It was hard-won. There is a nationally agreed set of terms and conditions under which all healthcare staff in HSC, with the exception of doctors and dentists, are employed. Those agreements are the basis for my Department's commitment to pay parity with England. The part of the motion that refers to harmonising healthcare pay rates poses me, frankly, an enormous problem.

Members will be aware of a Strategic Investment Board (SIB) assessment of pay and related issues across the public sector in Northern Ireland. My Department will engage with the Strategic Investment Board to look at wages, the cost of living, tax and other relevant factors across all neighbouring jurisdictions, including the Republic of Ireland. We need to better understand the differences between jurisdictions and attempt to determine potential areas of focus for our region. We should be mindful that different taxation rates, housing costs and overall cost-of-living factors are key parts of the picture alongside pay.

Waiting lists are a big concern for all Members, and, at this point, I make a plea to them. It is easy to make demands in the House for more investment in staff pay, tackling waiting times and a long list of other areas in which improvements are badly needed. We cannot be blind, however, to the current budgetary realities. We cannot engage in denial. Our waiting lists are not good. We can all agree on that. I fully understand the distress and anxiety that long waiting times cause, particularly when patients are suffering pain and discomfort. Long waiting times also have a societal impact that goes much wider than individuals. Waiting times in Northern Ireland are wholly unacceptable, and tackling them is one of the areas on which I have committed to focusing over the next three years.

Some progress has been made under the elective care framework, but there is much more to be done. The framework, published in June 2021, was updated on 24 May this year. It sets the strategic direction for the development and reform of effective and efficient delivery of elective care services here over the next five years, and it details measures that are needed to address the unacceptable waiting lists. For many years, we have been heavily dependent on the availability of additional, non-recurrent funding to tackle waiting lists.

The funding has been used to secure extra capacity both in-house and in the independent sector, including providers in the Republic of Ireland, across a range of elective specialities.

Nuala McAllister asked about returning to the Committee with thoughts about bringing back cross-border programmes. We shall do that in due course. The Member also asked when we will have news about the structure of our hospital network and suggested that there would be a statement in June. However, it is more likely that it will come before the House in the week beginning Monday 8 July, because of the general election purdah period.

In addition, my predecessor introduced the Republic of Ireland reimbursement scheme in June 2021 as part of the elective care framework to help reduce lists. The scheme provided an option for patients to seek and pay for routinely commissioned health service treatment in the private sector in the Republic and have the cost reimbursed up to the cost of treatment to the NHS in Northern Ireland. I take Mrs Dodds's point that some cannot afford to pay up front.

I am running out of time, so I am glad I did not go for the 12-minute option before we broke. I acknowledge that Mr Donnelly said that the Bengoa report is on the shelf: it is not on the shelf. Some actions have been taken: for example, the day procedure units at Lagan Valley and Omagh Hospitals. I can inform the House that I was in discussions with Professor Bengoa as recently as yesterday, and he will have more to say about the reform of our health service in the months to come, certainly before the end of the calendar year.

Photo of Carál Ní Chuilín Carál Ní Chuilín Sinn Féin 3:00, 18 June 2024

Thank you, Minister. Recess is on Friday 5 July and not Monday 8 July, in case you want to bring something forward before that date.

I call Mark Durkan to make a winding-up speech on the motion. Mark, you have 10 minutes.

Photo of Mark Durkan Mark Durkan Social Democratic and Labour Party

Go raibh maith agat, a Phríomh-Leas-Cheann Comhairle.

[Translation: Thank you, Madam Principal Deputy Speaker.]

We have a health system whose prognosis is critical, where "urgent" no longer means "urgent", and "red flag" has lost its urgency. Patients face prolonged waits and uncertainty at the expense of their health. The erosion of those categorisations reflects a system under immense strain where timely access to care not only is compromised but, in some cases, seems to be a pipe dream. Practically every health service waiting list in the North is breaking records: bad ones. Half of the people waiting to access mental health services wait longer than nine weeks. Over 17,000 people are on a waiting list for occupational therapy and have been stripped of their dignity. Almost 25,000 people await orthopaedic surgery, with some, crippled by pain, being told they will wait seven years to access a knee replacement. How is that acceptable? Patients across the spectrum of health services are being referred for treatment for conditions that were once manageable but have become unbearable as a result of the unconscionable delays. The failure to deliver timely healthcare not only costs the public purse dearly but costs lives.

We stand at a critical juncture, facing formidable health challenges that were not created overnight. In fact, pre-pandemic, our waiting lists were 100 times bigger than those in England, a region with 30 times the population of here. The festering wounds of the health service went unsalved during political collapse. Past Health Ministers have failed to invest in health, and that saw our workforce driven to the picket lines not just to demand fair pay but to fight for the safety of the patients whom they care for. There was little attempt to resolve the situation. As a result, health has paid the heaviest price after more than a decade of mismanagement of, albeit, a shrinking public purse by the two big parties and a refusal to implement transformation as per the Bengoa report. The Executive had the key to reforming the health system but did not bother to turn the lock.

Embracing cross-border healthcare is born of necessity but also practicality. It is an imperative response to our growing waiting lists and healthcare disparities. As has been highlighted, collaboration with the South will allow the maximisation of available healthcare resources, provide opportunities for medical professionals through shared expertise and offer the potential for cost savings and better allocation of healthcare funds.

Photo of Mark Durkan Mark Durkan Social Democratic and Labour Party

I am sorry. I will come to you at the end, if I have time, Patsy.

The success of the ROI reimbursement scheme is testament to the need to drive cross-border solutions. During its last iteration in 2022, over 2,000 patients availed themselves of the provision in just 14 months. People are contacting my office and, I am sure, those of others by the dozen, desperately seeking updates on the return of the scheme.

Painful time frames prove devastating for patients and their families. People are living in agony, their lives turned upside down in a health system that no longer catches people when they fall. Patients are turning to their credit union books, dipping into their life savings or, even worse, borrowing money from God knows who and God knows where to access healthcare. That is becoming an all-too-familiar story. While the scheme was not perfect, as Mrs Dodds was eager to point out, it offered a glimmer of hope.

The current system is ridiculous. We have patients criss-crossing the border weekly in their busloads for procedures in the North, such as cataract surgery; meanwhile, patients here cannot access the same treatment in a timely manner. That said, the North West Cancer Centre stands as a shining example of successful cross-border collaboration. Its success underscores the power of partnership and regional cooperation in delivering specialised healthcare services where they are needed most. I am conscious that it was the Speaker who was Health Minister at that time, as he often reminds us. Sadly, the pragmatism and vision that he demonstrated in that role seems to be lacking in his colleagues today.

Despite the state-of-the-art cancer services in the north-west, widening health inequalities have hit hard in that highly deprived region. The fact that a child in Derry has a life expectancy that is 11 to 15 years shorter than that of a child in a more affluent area is harrowing. The expected lifespan of a man in Derry is lower than one in countries such as Lebanon and Cuba, according to research conducted by the Department of Health. The state of health here is not like Beirut: it is worse. It is incredible that, in a place as small as Northern Ireland, there are such disparities across and within council areas.

The largest inequality gap in the Western Trust and other trust areas was in deaths due to drug misuse. We see the impact of drug misuse and addiction: the bereaved parents whose lives have been shattered and the individuals feeling that they have nowhere else to turn. The escalation both in the severity and volume of cases is heartbreaking. At the moment, far too many vulnerable people fall through the gaps of addiction and mental health support services, and many cross the permeable border daily. It is no coincidence that drug-related deaths have trebled in a decade. It is a direct consequence of Tory austerity and failed leadership here.

On the motion, the harmonisation of pay, especially in border regions, is of particular importance to prevent our specialist staff leaving in their droves. It used to be the case that nurses, doctors and allied health professionals (AHPs) had to take a plane across the water or across the world for better-paid opportunities. Now, they just have to hop into their car and drive a few minutes down the road. Recently, I spoke to one health specialist who is paid two thirds more for her expertise across the border, as are several of her ex- and now new colleagues, who have headed South for more reward. Who would blame them? The failure to pay health service staff what they are worth is an embarrassment; worse than that, it is draining the lifeblood of the health system, and any savings that it achieves are false. Look at the spending on locums and agency staff and at the failure to deliver services. That is something that I implore the Minister to consider with regard to the capitation formula for trusts. He spoke of Agenda for Change and the need for pay parity. There has to be a weighting in border areas to prevent that haemorrhaging of staff across the border.

The Health budget is stretched to breaking point like a threadbare blanket, unable to cover all the needs. Inevitably, vulnerable people will fall through the gaps. However, we are no clearer on how the Government plan to address the crisis in health, and where are we with transformation? It is all well and good pumping money into a system — I wish that we could pump even more into it — but that system is crying out for reform. We need to do things differently to ensure maximum impact of the money that is spent.

We should explore or do more than explore all-island collaboration on bespoke specialist areas such as tier 2 obesity services, cross-border enhancements in social work services in safeguarding and data sharing, as well as perinatal and paediatric pathology services. That is vital. It is unacceptable that, since 2019, post-mortem examinations have had to be carried out in England due to a lack of specialist staff, adding further distress to grieving parents. Five years ago, I received assurances from the permanent secretary that work was under way to seek a cross-border solution. It is unforgivable that, to date, there has been no progress.

The DUP's position on this and its rationale for opposing the motion are typical of its approach to nasal amputation: it cuts off its nose to spite its face, an approach that continues to cost people dear. It is no wonder that our health service is in such a state when you look at the approach of our two biggest parties. They say that health is a priority when, clearly, politics always comes first.

Sinn Féin has had only one Member in the Chamber for the majority of the debate. I am glad to see that she has now been joined by a few more. I was worried that abstentionism had extended — sorry, been reapplied — to Stormont as well. I agree with Ms Kimmins's view, however, that getting into a car and driving, even for a couple of hours, is preferable for families to having to get on a plane on that most awful of journeys.

We must build a healthcare system that is responsive, resilient and compassionate —

Photo of Mark Durkan Mark Durkan Social Democratic and Labour Party

— a system that leaves no patient behind and values our heroic health service staff, who carry out Herculean tasks daily.

Photo of Carál Ní Chuilín Carál Ní Chuilín Sinn Féin

Go raibh maith agat as sin.

[Translation: Thank you for that.]

Question put and agreed to. Resolved:

That this Assembly acknowledges the daunting challenges facing our health service; laments that Northern Ireland has fallen behind the Republic of Ireland and the rest of these isles on several healthcare outcomes; understands that a solution to our healthcare challenges will not come solely through increased funding, but also through reform of our services; recognises that a key element of this will be further collaboration with the healthcare service in the Republic of Ireland; acknowledges that certain bespoke specialist services, in particular perinatal and paediatric post-mortem services, which are currently not available in Northern Ireland, could be delivered more efficiently and compassionately on an all-island basis; calls on the Minister of Health to work with the Irish Minister for Health to identify how the two jurisdictions can work together to reduce waiting lists, harmonise healthcare pay rates, and deliver bespoke specialist services on an all-Ireland basis.

Photo of Carál Ní Chuilín Carál Ní Chuilín Sinn Féin

I ask Members to take their ease, please, because we need the Minister in the Chamber for the next item.