Joint Committee on Health debate -
Wednesday, 8 Mar 2017

Implications for Health Sector of United Kingdom's Withdrawal from the EU: Discussion

Chairman

This afternoon we are meeting officials from the Department of Health to discuss Brexit. The purpose of the meeting is to discuss the implications for the health sector of the decision of the United Kingdom to withdraw from the European Union. On behalf of the committee, I welcome Mr. Muiris O'Connor, Mr. Fergal Goodman, Mr. Tom Monks, Mr. Kieran Smith and Ms Sarah Rose Flynn of the Department.

I wish to draw their attention to the fact that by virtue of section 17(2)(l) of the Defamation Act 2009 witnesses are protected by absolute privilege in respect of their evidence to the committee. However, if they are directed by the committee to cease giving evidence on a particular matter and they continue to so do, they are entitled thereafter only to a qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable. Any submission or opening statement they have submitted to the committee may be published on the committee website after this meeting. Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the House or an official either by name or in such a way as to make him or her identifiable.

I also remind members and witnesses to turn off their mobile phones or switch them to flight mode.

I now ask Mr. Muiris O'Connor to make his opening statement.

Mr. Muiris O'Connor

I wish to begin by thanking the committee for inviting us to talk about the implications for the health sector of the United Kingdom's decision to withdraw from the European Union. I will introduce myself and my colleagues. I am Muiris O'Connor, assistant secretary in charge of the research and development and health analytics division in the Department of Health. I am joined by Fergal Goodman, assistant secretary in charge of the primary care division, along with Tom Monks from the eligibility and primary care policy unit, Kieran Smyth, head of the international unit in my division, and Sarah Rose Flynn, also from the international unit. I will begin by setting out the wider context of the Brexit challenge. I will also use my opening statement to briefly outline the principal impacts for the health sector and the work we are undertaking to examine and address those impacts.

The overall priorities of the Government regarding Brexit are clear. They are to minimise the impact on trade and the economy, protect the Northern Ireland peace process, maintain the common travel area and influence the future of the European Union. Preparing for Brexit is a whole-of-Government task. The Department of Health is participating fully in the structures co-ordinated centrally by the Department of the Taoiseach to ensure a joined-up approach. It is worth remembering that we are at an early stage in the Brexit process. The UK has not yet notified the EU of its intention to leave by invoking Article 50 and negotiations have not yet started. When negotiations do begin, Ireland will participate as one of the 27 member states remaining in the European Union. A great degree of uncertainty surrounding Brexit still remains. For example, we do not yet know what new arrangements may emerge as regards the UK's future relationship with the EU. We also do not know whether transitional arrangements will be put in place to bridge the gap between the UK's exit from the EU and the conclusion of an agreement on its future relationship with the EU, or how long a period such transitional arrangements would cover. This context of uncertainty makes conducting work to examine and address the implications of Brexit challenging. It also means that a definitive analysis is not possible at this stage. Nevertheless, our preparations are ongoing. The Department of Health will continue to revise and update its analysis as matters become clearer over the period ahead. As the committee will be aware, the Government is determined that all possible preparations will be made ahead of the UK leaving the EU and that the focus will be on protecting and advancing the interests of Irish citizens, within the context of this country's continuing membership of the European Union.

I will now set out some of the potential principal impacts of Brexit for the health sector. Firstly, however, I wish to note that the UK has not yet left the EU and remains a member, with all of its existing rights and responsibilities. This means there have been no immediate changes in the area of health care, nor are any expected during the negotiation period. The Department of Health has put in place a process and work is under way to examine and address any implications for the health sector over the longer term. All our work relating to Brexit is informed by the following key priorities: to ensure continuity in the provision of health services; and to avoid any changes to the current situation that would have a negative impact on human health. I will give an overview of some of the issues we have identified in our analysis, which will be deepened and refined as time goes on.

The principal impacts of Brexit for the health sector cover a number of areas including free movement, rights to health services and regulatory issues. Brexit raises a number of issues relating to free movement and these affect all sectors. In the area of health, issues such as emergency ambulance transfers between Ireland and Northern Ireland and mobility for cross-Border health workers will need to be given due consideration. Regarding health services, ensuring that there is minimum disruption and that essential services are maintained on a cross-Border, all-island basis and on an Ireland-UK basis will be the key concern for the Department of Health over the period ahead. In particular, the Department is conscious that the operation of the EU treatment abroad scheme and the cross-border directive under which Irish patients currently enjoy the ability to access health services in the UK, in particular in Northern Ireland, may be affected by the UK leaving the European Union. The common travel area has been in existence since Irish independence. It allows freedom of travel between the two jurisdictions for Irish and UK citizens and provides for largely reciprocal benefits of citizenship in terms of entitlements to reside, work and access services. These arrangements stem from the close historic relationship between the two countries and predate the entry of both into the EU. Both the Irish and British Governments have set out their desire to maintain these arrangements, and this will have relevance for the health sector.

Regarding regulatory issues, it is clear that having a single set of rules across Europe is enormously helpful to protect human health, ensure consumer protection and provide a level playing field for industry. A UK move away from a harmonised regulatory system in respect of food safety standards, pharmaceuticals, medical devices and cosmetics could disrupt trade between Ireland and the UK or necessitate increased certification requirements. It is important to remember that there are other issues that will affect the health system but which may not necessarily be led by the Department of Health. The Department is working closely and collaboratively with other Government Departments to examine and address these issues, including through the interdepartmental group on EU and UK affairs. Cross-departmental work is essential in resolving issues. For example, the Minister for Public Expenditure and Reform and his Department have successfully secured certainty for the EU-funded cross-Border co-operation programmes PEACE and INTERREG, which includes a number of health projects, up to 2020. The Government is committed to securing EU funding for successor programmes post-2020. The strength of the relationships between Ireland and Northern Ireland and the UK will be of benefit as we work to find solutions to any problems that arise for the health sector as a result of Brexit. There are already effective partnerships and working arrangements in place and many examples of practical and effective co-operation between the jurisdictions for mutual benefit in the health sector. The Department of Health remains strongly committed to continued co-operation with Northern Ireland and the UK in the health sector.

As well as preparing for the challenges posed by Brexit, we are pursuing opportunities. The Government decided late last year that Dublin should be proposed as a very suitable location for the European Medicines Agency, EMA, which will need to move from its present home in London once the UK leaves the EU. The EMA is responsible for the scientific assessment with respect to the authorisation, maintenance and supervision of medicines in prescribed areas developed to protect human and animal health by pharmaceutical companies for use in the EU. The EMA is also responsible for monitoring the safety of all medicines authorised in the EU. Detailed work is under way under the auspices of an interdepartmental and inter-agency group led by this Department. An extensive programme of ministerial and official-level engagement is also under way in support of Ireland's bid. I would be happy to expand on this if the committee so wishes.

I will turn now to the programme of engagement under way on Brexit, the structures that have been put in place across Government Departments and the work the Department of Health has carried out to date. An extensive programme of Government engagement is under way on Brexit, led in particular by the Taoiseach, Minister for Foreign Affairs and Trade and Minister of State with responsibility for European affairs. Ministers are meeting their EU counterparts at Council meetings and other events, while officials are maintaining contact with their counterparts in other countries. The Minister for Health has met with the European Commissioner for Health and Food Safety twice in recent months to discuss the impact of Brexit on Ireland and the health sector and to discuss Ireland's bid for the European Medicines Agency. The Minister also met his Northern Irish counterpart at the North-South Ministerial Council health sectoral meeting in November, at which a paper on "Implications of the UK Referendum" was discussed. He has also discussed Brexit with the UK Parliamentary Under-Secretary of State for Health, the UK Secretary of State for Health and the Scottish Cabinet Secretary for Health, Wellbeing and Sport. At official level, this Department has proactively engaged with officials in the Northern Ireland and UK Departments of Health. The potential impact of Brexit on health services has been examined and explored. It is intended that this engagement will be ongoing and will be strengthened as we get more clarity on the actual Brexit arrangements that might emerge.

Ireland's preparations for Brexit continue to be strongly co-ordinated from the centre of Government through the new Brexit Cabinet committee chaired by the Taoiseach. The Department of Health participates fully in the senior officials group on EU affairs, the interdepartmental group on EU-UK affairs, and its work groups established to support the Cabinet committee on Brexit. The Department established a management board sub-committee on Brexit in advance of the UK referendum to examine the implications of a decision to leave the EU. The sub-committee is chaired by my colleague, Deputy Secretary General Colm O'Reardon, and made up of representatives from across the Department, as well as from the HSE, which is represented by the national director of primary care. Our preparations for Brexit are under way and progressing well. The Department of Health is building on initial work undertaken to conduct a more detailed analysis on the impacts of Brexit in the area of health. Individual units in the Department and agencies are conducting analysis and continuing their contingency planning to identify the best strategies to mitigate each of those impacts. In addition to regular contact with agencies, Brexit is now being formally included as a standing item on the agenda of governance meetings between agencies and their responsible line units in the Department. The sub-committee serves as a co-ordinating body to pull the various strands of this work together and facilitate information-sharing.

Our continuing assessment of the implications of Brexit in the area of health is part of ongoing Brexit analysis and scenario planning for input into larger Government deliberative processes. Until such time as the UK’s relationship with the EU following its withdrawal becomes clear, the precise implications of Brexit for the area of health will remain unclear. A comprehensive analysis of the health implications of Brexit will have to be informed by the UK’s intentions in this area. Our focus will remain on ensuring that services for patients are maintained and human health is protected.

By way of conclusion, the Department of Health, in co-operation with its agencies and other stakeholders, will continue to deepen its analysis of how best to mitigate the impact of Brexit for the health sector over the period ahead. We will continue to engage with our EU partners, the UK and Northern Ireland, particularly as positions crystallise on areas of shared interest relating to the health sector in a post-Brexit context. I hope my opening statement has been helpful and I look forward to the committee’s questions.

Deputy Billy Kelleher

I welcome the witnesses and thank them for the presentation. Like all the debate around Brexit, uncertainty is the major backdrop in all of this. Very often, we are potentially planning in the dark but we must anticipate certain issues that may arise and have contingency plans in place. If there is potentially to be a hard Border of some form or another, the issues of concern are that there could be difficulties with the free movement of goods and services between the Republic of Ireland and the North, creating difficulties for commerce, movement of services and people. That could have a potential impact in the health area as well.

We have referenced rare diseases on numerous occasions. We have a population of 4.6 million people here and there are approximately 1.9 million people in the North but there must be close co-operation in order to achieve economies of scale. We may not have enough expertise on either part of the island but collectively we have a critical mass in the area of rare diseases, not only with respect to the number of people with rare diseases but, more importantly, of clinicians and specialists who would be able to operate on an all-island basis. If we ever get our children's hospital built - I assume it will happen at some stage - this issue may arise more frequently due to the fact that we would have a centre of excellence in Dublin that might be able to address some issues in the North as well as the South, with clinicians in both areas working in collaboration. I have referenced rare diseases and the issue of paediatrics but that could be broadened to other areas, such as transplanting and other high-end areas. What observations do the witnesses have in that respect? With regard to the registration of medical practitioners, such as consultants and nurses, etc., we have two administrative areas. Do the witnesses foresee any difficulties in that context with regard to registration and people living in the North and working here or vice versa?

Reference has been made to the treatment abroad scheme on a number of occasions, as well as the cross-border health care directive. In fairness to the Department of Health and HSE, it does not seem to advertise that much for fear people might find out about it. There are two schemes. The first is the treatment abroad scheme, for which people can make an application if the consultant can verify it is clinically acceptable and treatment cannot be provided in this country. Alternatively, the cross-border health care directive allows for a person entitled to public health care here to avail of it elsewhere if he or she so wishes. Do the witnesses foresee any difficulties in that area?

There is the issue of public health policy in general and health promotion in the context of wellness and having a healthy lifestyle. There is also the issue of vaccines. The greater the core of a population that is vaccinated, the more impact there is. Has anybody considered this issue with regard to development of vaccines down the road and all that flows from it? The more people who partake in a vaccination programme, the greater the coverage and the smaller the risk of cross-infection, etc. Has any thought been given to that? I do not expect full and detailed answers but the issues have been brought to my attention by clinicians and professionals.

Clinical research is sometimes bolstered by co-operation between industry and colleges. We have a reasonable footprint of pharmaceutical and medical device companies that co-operate with universities and institutes. The larger the pool of research available, the better the chance of superior outcomes. I hope those issues are kept to the fore in Brexit discussions to ensure we can manage them.

Deputy Louise O'Reilly

I thank the witnesses for their attendance and presentations. I was struck by the frequent mention in the opening statement of analysis and what might happen in future. I was in Donegal and Sligo fairly recently and people are very occupied with the implications of Brexit. They fear the Government and the various Departments are not as occupied and from listening to this, I tend to agree with them. This is very high on aspiration but frighteningly low on detail.

With regard to work done to date, has an exercise been carried out to quantify the amount of work and extent to which our health service is reliant on the National Health Service, NHS, with regard to the cross-border directive and other issues? The radiotherapy unit at Altnagelvin has a very recent service level agreement with the HSE. Has that been Brexit-proofed? I am willing to be corrected but my understanding is it was signed after the vote in Britain. If the agreement has not been Brexit-proofed, I would be very disturbed about how serious is the Department in dealing with the issue.

The next issue relates to the extent to which we are reliant on the NHS in the North and in Britain. Is there a plan B, as scenario planning has been mentioned? Is one scenario what will happen if there is a hard Border and in the event that it becomes more difficult for people than it is now? I know people in County Donegal, for example, who will rely very heavily on the services in Altnagelvin. A hard Border will be quite frightening for those people. Specifically, there is the issue of transplants. I am sure the witnesses are aware of media reports of difficulties that our health service has in trying to hit required times in this respect. We have our own problems in the Twenty-six Counties and they have been aired in the media. I know there is a service in the North but has advance planning been done with regard to that vital service and how we can avail of it?

There has been mention of what is happening at the Department but what is the involvement of the HSE?

I ask for a list of the HSE groups that have been established and the work done to date. Much of this references the work of the Department. The involvement of practitioners and those delivering health services on the ground will be essential in contingency planning. I fear that five minutes before the border is put in place someone will say, "Well, Jim, we had better put a plan together for how we are going to manage without being able to access services in the North." Perhaps the delegates might put my mind at rest.

Who from the HSE is involved in the working groups? If they are not involved, do they have their own group? If they do have their own group, what is the level of communication between the departmental group and the HSE group? How will it be managed?

Mr. Muiris O'Connor

I will take most of the questions, while Mr. Goodman will speak about the cross-border health care treatment directive and the treatment abroad scheme.

Deputy Louise O'Reilly asked for reassurance on the comprehensiveness of our preparations. I can reassure the committee that the Department is fully engaged and has been since before the Brexit referendum in the United Kingdom. It is a very comprehensive engagement with the challenges. All units are working with it and liaising with the agencies. There is a sub-committee of the management board on Brexit which co-ordinates our involvement at departmental level and connects us to the broader interdepartmental preparations for Brexit.

We have a national director of the HSE on our board and are engaging the HSE at all levels, particularly the North-South unit. The Department has been working closely with the HSE and other agencies to conduct an analysis of the implications of Brexit in the area of health. The Department also took part in an in-house seminar organised by the HSE for its organisation on the implications of Brexit. The North-South unit of the HSE has provided valuable expertise and assistance in examining the implications of Brexit for North-South co-operation and citizens in the area of health.

The Department and the HSE will continue to work closely together with the aim of ensuring minimum disruption in the area of health and that essential services will be maintained on a cross-Border, all-Ireland and Ireland-UK basis.

With some very senior members of the HSE, I recently attended an EU-exit health care workforce round table discussion with counterparts from Britain and Northern Ireland. We are very concerned about the concern in Border areas about the continuity of services. We were asked about the extent to which Altnagelvin Hospital is Brexit-proofed. It operates a joint service level agreement on radiotherapy services between the Western Health and Social Care Trust in Northern Ireland and the HSE. There is good will on both sides and a determination to continue and deepen co-operation.

Deputy Louise O'Reilly

Excuse me, but I asked a specific question about the actual agreement. I respect the aspirations of the people involved, but has it been Brexit-proofed, given that it was signed after the referendum had taken place? Does the SLA include a section which deals specifically with Brexit? If it does not, that is fair enough, but I would be surprised if does not. If there is, I ask Mr. O'Connor to outline some of what it includes.

Mr. Muiris O'Connor

I do not know if there is a specific reference to Brexit; I do not believe there is. However, there is a comprehensive memorandum of understanding underpinning it which provides an overarching framework for collaboration between the two jurisdictions on the centre. As well as agreement between the Departments of Health, North and South, it is primarily a service level memorandum of understanding between the service providers. To the extent that free movement is allowed at the end of negotiations as they evolve across the Border, we are very confident that there will be minimum disruption to services.

Deputy Louise O'Reilly

What is the basis for Mr. O'Connor's confidence? I would not be confident and certainly would not be confident, given that the SLA does not include a reference to Brexit, perhaps one of the biggest things to happen in the health area in the North. If it is not stipulated in the SLA, from where does Mr. O'Connor derive his confidence that everything will be grand? The view of people living along the Border is that the Department of Health and other Departments are stating, "Sure we will be grand," and they are hoping they will be. When Mr. O'Connor says he has confidence that everything will be fine, although we have not included it in the essential agreements, it does not strike me that the Department of Health is planning seriously for Brexit. If there is a hard border, there will be huge issues. The SLA is predicated on the cross-border health directive and people being able to move freely. If they cannot move freely, which is a possibility, it will be too do anything late five minutes before the lads with the shiny buttons put up the customs posts along the Border. We have a chance to start planning for it. Mr. O'Connor is saying he is confident that it will be grand, but I am not hearing anything that backs up that confidence.

Mr. Muiris O'Connor

The Department is not in any way complacent about the implications of Brexit. However, the MOU underpinning the co-operation on radiotherapy services in Altnagelvin Hospital was signed in 2014 and I do not believe there was any awareness of an impending Brexit referendum at that point.

Deputy Louise O'Reilly

Was the SLA not signed subsequently?

Mr. Muiris O'Connor

The MOU was signed in 2014. I do not have a date for the service level agreement. The MOU provided for investment from both sides in the capital development of the facility. Services commenced late last year and it is recognised as a very important service. The Deputy is articulating very well how important it is to provide prompt care for the people of the north west, including those in this jurisdiction. I did not mean to sound at all complacent in saying I was fully confident. We are exploring and working very closely in the Department and with counterparts in Northern Ireland to ensure the continuity of these very important services which are highly appreciated on both sides of the Border at official level and among the general public. They are critical services and a real priority for us in our planning for Brexit.

Deputy Louise O'Reilly

Can we get a copy of the SLA?

Mr. Muiris O'Connor

Yes, I would say so.

Deputy Louise O'Reilly

I think it was signed after the Brexit referendum. I understand the MOU was signed a while ago, but it contains all sorts of information on the development of the service. However, the SLA is specific to service delivery and it would be useful for us to see it. In the future all SLAs with a North-South dimension will need to be Brexit-proofed. That would allow people to say they were confident. Without it, the confidence seems to be somewhat misplaced.

Mr. Muiris O'Connor

Deputy Billy Kelleher sought an assurance that North-South co-operation was a factor. It has been well documented that North-South collaboration in the health arena is real and that real benefits accrue to citizens. There are many examples which illustrate the level of co-operation between the North and the South on health issues. As the committee is well aware, North-South co-operation on health matters takes place through the North-South Ministerial Council, as well as through joint departmental projects. There has been significant cross-Border health and social care activity in the past decade or more. Matters being considered and progressed in the North-South Ministerial Council since its commencement include health promotion campaigns on such issues as alcohol, tobacco, obesity, cancer services, research, suicide prevention and food safety. We will include the specific issue of vaccines in our analysis. The chief medical officer's team is looking at the general implications of Brexit. That is one we will bottom out in considering the implications.

Significant projects have been undertaken in recent years and they have made a difference to the lives of patients. Deputy O'Reilly referred to the Altnagelvin Area Hospital radiotherapy unit that was completed last year. Deputy O'Reilly adverted to how it provided access to radiotherapy services for people in the north west of the island, including people in this jurisdiction. Other important examples of cross-Border collaboration include the primary percutaneous coronary intervention services - also known as stenting - in Altnagelvin. The arrangement allows Donegal patients to have access to these services on a 24-7 basis. In July 2016, the then Northern Ireland Minister of Health, Ms O'Neill, and the Minister for Health, Deputy Harris, opened the hybrid cardiac catheterisation laboratory at Our Lady's Children's Hospital, Crumlin. The laboratory provides emergency surgery to babies born with congenital heart disease in Northern Ireland in addition to providing services for patients in the South. As Deputy Kelleher pointed out, these are good examples of how North-South collaboration can generate the critical mass of patients to make services of a specialist nature feasible at local level.

Chairman

There was a question on the registration of doctors and nurses.

Mr. Muiris O'Connor

Yes, that is an important aspect in terms of regulation and the mutual recognition of professional qualifications for doctors and all health and social care professionals. It is singularly helpful that within the European context there is mutual recognition of all these qualifications. There are serious implications for this area. From day one of the UK leaving, those responsible in the UK are likely to mirror the existing EU arrangements. Much will depend on the inclination of the UK as regards UK professional qualifications thereafter. There is an eagerness at official level and among professional bodies to maintain the equivalences in place as well as the mutual recognition of qualifications, but we cannot take anything for granted. Further and closer engagement with our Northern Ireland and UK counterparts as well as with the broader European Union will be important.

I and senior HSE people attended a discussion recently up North. The idea was to broaden and deepen our understanding of the potential implications and preparations. However, it became clear that it is not only a question of member state governments but also a matter for the royal colleges and the professional bodies associated with the recognition of qualifications in various jurisdictions. This area will require substantial further work. It is an area of key importance.

Deputy Billy Kelleher

Often, the easiest way to keep people from coming into a country in a professional capacity is simply to change the recognition criteria. Straight away, it results in paperwork and delays and so on. It was the oldest trick in the book for many years and one applied by protectionist countries. Mr. O'Connor is suggesting that most of the professional bodies in the UK as well as officialdom would be supportive of the present regime. Is that correct?

Mr. Muiris O'Connor

I do not want to be too definitive about that in terms of our initial engagements.

Deputy Billy Kelleher

Does the Department of Health take the view that those responsible in the UK want to change it?

Mr. Muiris O'Connor

No, there was an eagerness to maintain things and recognition of the benefits that arise. Much of this will be political and, politically, it is unclear what direction the UK will take.

Deputy Kelleher also referred to clinical research and co-operation between higher education and industry as well as the extensive co-operation between Ireland and the UK. This area is very much in the frame for us. It is led by the Department of Education and Skills but the Department of Health has a major interest because of the importance of health research.

In a sense, our approach is two-pronged. The first is to sustain and continue to develop the existing research collaborations with the UK and Northern Ireland. However, there is recognition that we must broaden our partnerships into the other 26 countries, in particular under the EU Horizon 2020 fund. Ireland has an ambitious target to get €1.25 billion between 2014 and 2020. It is unclear whether the UK would be automatically expected to leave or to what extent eligibility for Horizon 2020 would be affected, although there are some indications that the UK may be willing to continue to engage with the programme. In any event, there is a major opportunity for us perhaps to increase our share of European research funding drawdown and to build and deepen our partnerships beyond the UK in research.

Mr. Goodman will address the questions on cross-Border health care and the implications for the treatment abroad scheme.

Mr. Fergal Goodman

If Mr. O'Connor does not mind, I might touch on one or two of the issues mentioned. I was not inclined to cut in while he was speaking, but I will elaborate on one or two points.

The first relates to the scenario when Brexit happens. As was said in the introductory statement, much of this will revolve around what happens with the common travel area. If this goes in one direction, we have a rather favourable outcome. If it goes in another direction, things could be far more difficult. I agree that we need to plan for the scenarios and consider the spectrum of things that might happen. That is what we are doing. However, at a certain point it becomes speculative in respect of what any of us believe will happen. We are dependent on what direction things move in that regard.

When it comes to professional mutual recognition and so on, Ireland is not the only country affected. We feel an especial closeness and there is a good deal of collaboration backwards and forwards. Irish students are training in the UK and they then want to practice here and so on. That is a matter of great consideration and importance for us. However, Ireland is not the only country of the remaining 27 countries so affected. We do not have a solo position that we can put out and run with. As was said at the outset, we are part of a wider engagement process between the EU and the UK. Department of Health officials and our Minister have to be cognisant that we are part of that overall framework.

North-South issues have been touched on to a considerable extent. I am aware from speaking to colleagues in the Department who are involved and, as Mr. O'Connor has said, from contact with counterparts in Northern Ireland that there is a strong desire to maintain the cross-Border collaboration relating to Altnagelvin and paediatric care issues in particular. It is important to note that these are not carried out or provided for under the EU directives. They are not part of the treatment abroad scheme, for example. They are predicated on memoranda of understanding or service level agreements between the statutory health authorities on the two sides of the Border. If we take the travel permissions issue out of it, there should be few, if any, impediments to the continuation of the arrangements. This is the view of officials in the Department of Health. Certainly, that is the objective we strive to achieve. In other words, regardless of how Brexit plays out, we will maintain and continue those services, some of which are still only in the developmental phase.

It is important the committee understands the strength of our determination to ensure we adapt to what might come out of the Brexit process. We cannot predict it at this point. I fully admit that.

Reference was made to the treatment abroad scheme and the cross-border directive. We undertook some initial analysis of how these are working. The cross-border directive is rather new. Deputy Kelleher asked whether it was being promoted. When the directive was developed, there was a general consensus across EU member states that the scheme was not to be strongly and highly promoted by national health systems. That was the consensus view at European level and we need to respect that. However, it has been promulgated to the medical associations. It has been promulgated at operational level, in other words, at hospital level and hospital group level, in terms of making information available to patients. Also, the HSE has a particular national contact point and considerable information is available on the HSE website. It is still in the early years of implementation. Certainly, it is instructive to look at the analysis of developments on the cross-border directive. We would be happy to share the data with the committee. We can provide it afterwards, if members wish.

A total of 237 inpatient treatments were done and reimbursed under the cross-border directive in 2016, with 213 done in Northern Ireland. Therefore, 90% of inpatient cross-border treatments went to Northern Ireland. Outpatient and day cases are lower at 31%. We do not know how much of the remaining 70% or so outpatient work went to other parts of the UK. Intuitively, one would feel that it could be significant. We do not have that data yet. We are seeking that detail from the HSE's analysis but it is fair to assume that the cross-border directive - for cultural and other convenience reasons - operates primarily as an Ireland-UK facilitation.

Deputy Louise O'Reilly

Mr. Goodman does not yet have the data on the extent to which we were reliant on the NHS to treat people in 2016.

Mr. Fergal Goodman

Of the 1,738 cases last year, approximately 700 went to Northern Ireland. We do not have a country breakdown at this point for the remaining 1,000. It is not an unfair working assumption that many of those went to the UK. The more we assume it is the UK, the more significant is the issue. We are, therefore, not seeking to down play the significance of what could be at play here.

Deputy Louise O'Reilly

One of my questions relates to the extent to which are we are reliant on the NHS-----

Mr. Fergal Goodman

This is specifically for the cross-border directive.

Deputy Louise O'Reilly

Let me finish. The answer I have been given is that the Department is speculating. We are discussing the implications of Brexit. The first action that should be taken is an analysis of the extent to which the cross-border directive, which may not survive Brexit, is contributing to the HSE's work. When will Mr. Goodman have data on the extent to which the rest of the NHS is picking up the slack here? I understand that 90% of the inpatient treatments were performed in the North.

Mr. Fergal Goodman

It would not be fair for me to put a date on it. We have requested that from the HSE as part of the analysis. We are continuing to refine and develop our analysis and we will have that information quite soon.

Deputy Kate O'Connell

Could Mr. Goodman repeat the figures? Is 700 the total?

Mr. Fergal Goodman

A total of 1,738 cross-border directive cases were reimbursed in 2016, of which 692 went to Northern Ireland. I acknowledge that it is difficult to read out a table and give figures to members but out of a total of 237 inpatient cases done under the directive, 213 went to Northern Ireland, which gives the 90% I referred to. Of the 1,501 outpatient and day cases reimbursed, 479 went to Northern Ireland. I do not have a country breakdown of the remaining 1,022 but we know the countries where the directive has been exercised by people. Northern Ireland, England, Poland, France and Lithuania are instanced as countries of significance but we are seeking a country-by-country breakdown and the HSE has to run some analysis to provide that for us.

Chairman

Will Mr. Goodman send that information to us when he gets it?

Mr. Fergal Goodman

Absolutely.

Deputy Kate O'Connell

Is it a limited number of countries that people use?

Mr. Fergal Goodman

Those are the principal countries but there may one or two cases in other countries.

Deputy Kate O'Connell

It is not like there are 1,000 countries. It seems bizarre that Mr. Goodman would not know that patient X went to Poland and that such data are not available. Perhaps I am overreacting.

Deputy Louise O'Reilly

It is particularly bizarre in the context of Brexit, since that is what we are discussing, but the data are not available.

Deputy Kate O'Connell

When will we get this?

Deputy Bernard J. Durkan

And from whom?

Deputy Kate O'Connell

Will it be soon?

Mr. Fergal Goodman

The HSE runs a national contact and reimbursement service for the directive. We have requested more detailed analysis and that is awaited. It will not take that long but it would be speculative for me to put a date on when the committee will have it.

Deputy Louise O'Reilly

When was it requested?

Mr. Fergal Goodman

The more detailed breakdown was requested in recent weeks when we knew we were coming before the committee.

Deputy Louise O'Reilly

This goes to the heart of the issue I was trying to get at. It does not appear that advance planning is being carried out to any great extent. The Department waited for the committee to invite officials to discuss Brexit before seeking information from the HSE. If the Department was being proactive, with the greatest of respect to the officials, surely they should have that information. The vote on Brexit took place in the middle of last year. Should the committee write to them every week to say it wants them to discuss Brexit? This is a massive issue but they only requested the information from the HSE following the committee's invitation to appear. Mr. Goodman's opening statement is based on analysis that is being done and on deeper analysis. What are officials analysing if they have not discussed the extent to which we are reliant on the NHS to treat patients who should be treated here but are not? If they have not done that, what are they analysing? What planning are they doing to replace the directive? It does not seem that Brexit is a priority issue but it should be.

Mr. Muiris O'Connor

I assure the Deputy that it is a priority issue. We are awaiting a specific breakdown of figures for countries. We received an analysis from the HSE in its contribution to our management board sub-committee on Brexit across a wide range of issues. We are maintaining a risk register which was developed even before the referendum and we have continued to refine that. What is awaited is a specific set of figures. We are aware, as is the HSE, that the UK and Northern Ireland account for vast majority of destinations used by Irish citizens under the directive. It is not that we have failed to engage with these issues; we have discussed this in-depth and we continue to engage with it. The specific figures and country breakdown are awaited. This is not our first engagement with this issue and, therefore, we will provide them.

Deputy Louise O'Reilly

The specific figures and the breakdown are important and Mr. Goodman has just indicated that they were not sought until the officials were notified that they would be before the committee. I am not putting words in anyone's mouth because that is exactly what was said. If they are as proactive and confident as Mr. O'Connor claims, they will be to deal with this. That information would have been among the first sought months ago and, instead, a few weeks ago, on receipt of the invitation from the committee, information was sought. It is not beyond the bounds to suggest that there is a level of complacency because, clearly, the figures were not sought until an invitation was received from the committee. If we can get Mr. O'Connor's assurance that the information will be sought and worked on without the committee having to issue an invitation, that would be helpful. It would also be of some comfort to people in counties Donegal, Sligo, Cavan, Monaghan, Leitrim and elsewhere along the Border who are concerned about the implications of Brexit.

Chairman

Will Mr. O'Connor send us that information as soon as it is available?

Mr. Muiris O'Connor

Yes.

Mr. Fergal Goodman

The key point about the cross-border directive is that it is an EU regulation and applies only within the EU.

If the UK exited in a hard form, it would be outside the directive. It is a recent development at EU level and there was no reimbursement scheme prior to its institution. The challenge is to see if we could have a bilateral arrangement with the UK to maintain such a provision. Our overall objective is to maximise the continuity of the arrangements we have at the moment but the question of whether the cross-border directive would continue to involve the UK is an EU-UK discussion point. We are in a unique position in having a land Border with the UK but the cross-border directive also operates between the UK and the rest of the EU.

I want to be clear about the treatment abroad scheme. This is arranged on a consultant-to-consultant basis and operates when a treatment is required but is not available in Ireland, or only available outside the time required. We are very dependent on the UK for the scheme and in 2016 there were 636 cases, of which 574, or 90% went to the UK. We are particularly dependent on the scheme for paediatric, liver and cardiac transplants. The scheme will continue to operate within the EU but, as it is for services that are time-critical such as transplantation, it will be difficult to use France or other places in such cases. In the interests of continuity of quality and accessibility of service we will strive for an arrangement whereby we can continue the scheme but we cannot predict this and since it operates under EU regulations we will not have the facility to make a bilateral international agreement. We need the Brexit process to move on somewhat before we have greater clarity as to how we should move on this matter.

Chairman

Deputy O'Connell, Senators Colm Burke and Dolan and Deputy Durkan are next.

Deputy Kate O'Connell

There is generally an Irish arm of many multinational medication and drug manufacturers but MSD and Pfizer are based in the UK and we bring products here from these sources. Has the Department done any work on the implications for these products, particularly in the area of timelines? We now have same-day, or 24-hour, deliveries of drugs from the UK. Will there be increase in these timelines and what might the knock-on effect be for patient care? Time is money and, as is the case with hauliers, if things are delayed and turnaround times are increased there will be cost implications. These are hard to quantify and we do not know how long the delays will be but has any work been done to establish the effects and mitigate them?

Mr. Goodman spoke about the EMA in the context of the regulation of medications and appliances. If there is a hard Border, the UK will not be able to avail of mutual recognition and centralised procedures for medications. Is there any indication of what the UK plan is in this regard? It is a bit like a farmer's market, where everybody inside signs up to the charter of the market while there is a lad with a stall outside trying to sell carrots to the people in the market and he is not abiding by the rules of the market. Has the UK given any indication of the direction it wishes to take in this area? It is better to have a copy of the rules and be inside the market. Norway and Iceland have asked to be included in the current procedure but has the UK given any hint of what it will do?

Deputy Kelleher asked about regulation. I am a UK graduate and 25% of my pharmacy class in 1999 were Irish. We had a great time but this is a huge concern for me. Mr. Goodman said this was not specific to Ireland.

Mr. Fergal Goodman

There are other professions involved as well, although health is a critical area.

Deputy Kate O'Connell

This is the Joint Committee on Health - I am not trying to be smart. I imagine most people would agree that Ireland is disproportionately affected and would have a higher percentage of undergraduates and postgraduates in the UK. The argument is constantly being made that we cannot do anything until we know exactly what is going to happen but there are not too many permutations. One is either in the tent or outside the tent. The system is that one graduates in pharmacy in the UK and, having done one's registration year, becomes a member of the Royal Pharmaceutical Society of Great Britain, getting the same accreditation as here. It widens the pool of professionals and not one person in pharmacy in Ireland would deny that they have learned a lot from the Royal Pharmaceutical Society of Great Britain, a story that would be similar across all medical professions. It is a major concern, especially for those currently studying there who had planned their career pathways. This could be dealt with in advance of knowing exactly what was going to happen. Can the Department update the committee on the latest situation in this regard?

I have been thinking about the foot and mouth outbreak, swine flu and various other public health issues.

My father worked in the Department of agriculture during the past two outbreaks of foot and mouth disease and he told me about the amount of work that happened at the Border and the connection between Ireland and the UK in terms of trying to keep the country free of foot and mouth. That was the case also with swine flu. What I am talking about is connected with what Deputy Kelleher said about vaccines. This is about population health and how one deals with such issues when theoretically there might only be a hedge between two countries and viruses are not aware that there is a border.

My fifth question relates to the E111 cards. To clarify, they allow one to receive medical treatment in another EU country. What is the situation in that regard? Have the witnesses considered it?

I fully agree with what Deputy O'Reilly said. She asked how long ago were the data sought on people receiving cross-border health treatment. It seems bizarre that this information would only have been sought in recent weeks and that the question would not have been asked an hour after Brexit was signalled about how many people from here are being treated across the Border or across the Irish Sea. It is not as if we have a population of 50 million. There are not that many of us. I do not blame the witnesses; I blame the HSE. One should just be able to ask the executive and the information should be sent on a spreadsheet. I get very concerned when we cannot get information at the touch of a button or in response to an e-mail from the Department of Health to the HSE. We should be able to find out where 1,700 people are going. It is not 17 million, it is a very small amount of people. That information is significant. To be honest, that is stressing me out a bit because if we do not know that, what are we at?

Has work been done on abortion? I will refer to what was said by Sam Coulter-Smith is a very well known and eminent obstetrician. He said: "I suppose one of the fallouts from the recent potential exit of the UK from the EU is that the freedom of travel may be affected - and that will be something which will be important for this group of patients." I assume he is referring to women who are seeking abortions. Again, we are back to the area of speculation but it is a real issue when we have 70 women a week travelling out of this country to the UK to terminate pregnancies. We generously gave them the right to travel abroad so we would not have to deal with the issue in our country. Has work been done to examine that massive issue, namely, the 70 women a week who are travelling? Are there arrangements in place to try to deal with the issue as best we can if the situation changes?

Senator Colm Burke

I will be brief because many of the issues I wished to raise have been dealt with already. I wish to return to the figures for inpatient cases. As I understand it, of the 237 cases, 213 were treated in Northern Ireland, which means 24 were treated in the UK.

Mr. Fergal Goodman

Or elsewhere in Europe.

Senator Colm Burke

Yes. The figure of 24 seems very low to me. Is it the case that not every individual is counted under the cross-border health care heading? For example, is there an arrangement where someone in a hospital in Dublin goes straight to the UK because it is an urgent matter? I have dealt with a number of cross-border health applications. Could it be the case that figures are missing that have not been assigned under the cross-border health care heading? I had medical treatment outside of this country and I did not have to deal with the HSE at all. I did not get a bill from the UK where I had received the treatment. Is it the case that there is a far higher reliance on the UK than we realise, especially given that medicine has become so sub-specialised?

My second question relates to people living in this country who have retired here from the UK. What will that mean within the health service once the UK leaves the EU? What arrangement will we have in place in such a scenario? As a corollary, what about retired Irish people who now reside in the UK, whose children, for argument's sake, have emigrated there? Such people get an Irish pension and have never worked in the UK. Where will they fit into the arrangement and have we considered the issue of medical treatment? It has occurred in many families that parents have moved because their children are all in the UK.

Much of the scrutiny for training bodies, especially in respect of medicine, is UK-based. Given that the population is very small here, the UK body is often the governing body for qualifications. In some areas of Irish medicine, as few as 20 people are specialists in a particular area. How do we see that working from now on? Will the same recognition levels be in place or is it expected that they will change once Brexit occurs?

My final question relates to recruitment, especially of doctors. Reference has been made to that already. We are very much reliant on doctors who initially come from outside of the European Union to the UK where they work for two or three years and then come to Ireland. Is it expected that Brexit will have an effect on that flow of doctors? At any one time we have more than 4,500 doctors working in this country who are not Irish graduates. In fact, a large percentage of that number are not even EU graduates. If we then add in those who are UK graduates, the 4,500 number changes as well because we have many such doctors who are working in the Irish system. We have approximately 18,000 registered doctors. How do we expect the situation to change in the next few years, especially once Brexit occurs?

Senator John Dolan

I have a number of observations first before I get into the detail of the submission we received. I very much welcome the opportunity to get this report. It is more than timely for us to begin such an engagement.

What is important now is how the committee, the Department and the HSE – indeed the whole of Government – proceeds with the issue and that we do not just behave in a way that we are all very busy but that we are thoughtful and strategic in our approach. We must include a risk analysis. I suspect we will not be able to cover all the possibilities as if there were no clock ticking down. We need to do the risk analysis and ensure we are strongly working on areas.

That leads me to another observation, namely, that I suspect we all woke up the morning after the Brexit referendum and uttered a similar two or three words. Let us be honest about that. None of us was expecting it in any real sense. I do not mean just those present in the committee room but people in general. In effect, what we had was an intent to fire a starting gun, Article 50, and we are all finding it difficult to come to grips with it.

We can talk about Brexit but almost as if it is just another thing that is going to happen and we will have to get up afterwards. It is difficult to marshal ourselves. I am also thinking about the various interest groups, whether disability or broader civil society groups. We all need to help each other to get to grips with this and just get on with it because it is a live action now. We can do the analysis when it is over.

The opening statement provided by Mr. O'Connor and his team refers to the whole-of-Government task. We - not just the health committee - need to have a greater sense of the matrix of what is going on between different Departments and the system as a whole. One of the points made in the opening statement is "It is worth remembering that we are at an early stage in the Brexit process." We are, but it will clock on in ways that may not suit us. Therefore, the question - I do not particularly expect to be given a full answer to it today, but perhaps a framework of one might be outlined - is how we are best placed to work this process as best we can. This relates to risk analysis. Members have raised many very interesting matters that all need to be put into the mix. One of the final points under the heading "General Context" in Mr. O'Connor's statement reads:

This context of uncertainty makes conducting work to examine and address the implications of Brexit challenging. It also means that a definitive analysis is not possible at this stage. Nevertheless, our preparations are ongoing.

This is a hard space to be in because we do not know what will come up against us and we are caught between whether to wait to see what comes up against us or do some general scenario planning. I would like to get some sense from the Department of its key approach or framework to this kind of never-never land in which it finds itself. It does not know exactly what it is facing but it knows it will face any number of issues of greater or lesser intensity.

Further on in the statement, under the heading "Principal health sector impacts", the third bullet point states, "All our work relating to Brexit is informed by the following key priorities: to ensure continuity in the provision of health services and to avoid any changes to the current situation that would have a negative impact on human health." I do not say this with any disrespect, but anyone could have written that. They are very solid first principles. Going back to my previous question, what I am getting at is the question as to what the next piece is. What are the next few paragraphs that would come after these two principles? What is the evidence behind them and the analysis for moving on? That needs to come on fairly sharply.

Regarding free movement, if one goes out onto the street and asks anybody, he or she will name a few very important hospitals in the UK that have saved people's lives. I would consider the area of disability. Deputy Kelleher talked about rare diseases. Ireland is a small country. Even if one adds Northern Ireland, it is still a small outfit. We are dependent on expertise from the UK. Granted, it comes from other places too, but the UK has been very strong and world class on a range of the issues at hand. That is a real worry for people. The disability movement and other groups also need to play a part in trying to work through this, which is a point to which it would be useful to return. How will the Department, the HSE and others engage with civil society or the patient groups or whatever one wants to call them? We are all in this together. We will face the same problem after it.

Further on, the statement reads, "It is important to remember that there are other issues that will affect the health system but which may not be necessarily led by the Department of Health." This is critical. We are the health committee. The determinants of health is a module I would like to hear more about and one that needs to be worked on. Even the points that have been raised by example - products, free movement, the speed or slowness of borders - are outside health but impact on health.

Another quote from the statement is, "The strength of the relationships between Ireland and Northern Ireland and the UK will be of benefit as we work to find solutions to any problems that arise." Is this overly hopeful in nature? Sometimes, we all hope things will work out well. When push comes to shove, how good will good relationships need to be to deliver the goods? That is the question. They may still be very good relationships, but people may be hamstrung because they are on one side of the line now rather than on the other.

I wish to raise a very practical matter. I am not criticising anyone but I am bamboozled by the fact, referred to in the opening statement, that we have the Brexit Cabinet committee chaired by the Taoiseach, the senior officials group, the interdepartmental group, the working groups - sooner rather than later we will need a map or a matrix. Some of these matters are beyond the witnesses and are the business of others. Perhaps some of the matters I am talking about are about helping all of us to help others to start in a meaningful way to deal with this.

Those are my few points. I again thank the officials from the Department for being here.

Chairman

Just to concentrate minds, I remind the committee that we have another meeting starting at 4 p.m.

Deputy Bernard J. Durkan

Unfortunately, I will have to go to the Dáil for Question Time.

First, we should remember one thing: Brexit was not our idea. We did not invent it but there are consequences for us. The presumption on the basis of all the information so far is that it will be a stark, hard-line Brexit. The expert opinion we have to go on is that the former Prime Ministers, John Major and Tony Blair, have both come out in recent times and explained the ill-thought-out nature of the decision in the first instance. That is all in the ether now. We will have to do the best we can from what we have, but I would be wary of bilaterals, particularly at this stage, because we could very well talk ourselves out completely and find ourselves in a position along the lines suggested by a certain columnist in The Times of London in the past few days. That is not a place we want to be and it certainly would not be a strong position from which to negotiate. We should operate on the basis of the worst-case scenario, do what must be done and recognise that we are negotiating from inside the European Union. The lines have already been discussed by various people here. We should do our utmost to keep a single market on the island of Ireland. To those who say this cannot be done, I say it is in the interests of those on both sides of the Border that it be done. Again, I emphasise that we did not cause the problem in the first instance, so let us put the pressure on somebody else instead of being put under pressure to deal with this.

Freedom of movement will be gone if we have a hard Border. It is as simple as that. The hard Border is removed if the island of Ireland is treated as a single entity; likewise the common travel area and the customs union. All of this creates an absolute, distinct line. It is not a line in the sand; it is a Border that will have to be observed. Then we will be on the other side of the discussion table, talking to ourselves, in one sense, among the people on this island, but also talking as members of the European Union.

If we move away from that premise and start talking about bilateral trade agreements in the interim, we will not be in the European Union or, worse still, we will have a new European Union which will mean nothing and we will then have a reversion to the old system of having bilateral trade agreements for everything across the Union. All of the things to which we have become accustomed for nearly 50 years would go by the wayside and matters would be determined by the larger countries which always benefit most from bilateral trade agreements. That has always been the case. A certain newly elected person on the international stage said a good deal was one when he won in a bilateral. I presume that is what he meant.

There is much to play for. Brexit will have major implications, but we cannot do anything until we see what unfolds. However, to be ready we will need to raise the bar considerably. We need to be unabashed in the way we present our case. Our right to present it rests entirely on the fact that we did not precipitate this situation. What will unfold for Northern Ireland and us on this side of the island will not be of our making. It is in our interests to stand solidly in support of and protect our colleagues in Northern Ireland, into the details of which I will not go now. What will come remains to be seen. The North-South dimension is of common interest in the area of health and others.

My colleague, Deputy Kate O'Connell, asked why information on procedures was not available. The Chairman knows my view on that issue. One cannot have two masters. We have two entities, the Department of Health and the HSE. I have to ask myself all the time to which of them I should refer for the information required. We know that the information Deputy Kate O'Connell rightly said should be available at the touch of a button is not available. It is hidden somewhere in the HSE. However, it will not be the HSE but the Department of Health that will be involved in negotiating Brexit. I never understood why we went down the road of having to debate with two organisations, of having a two-pronged attack against ourselves.

There is a grave danger that we will find ourselves involved in itsy bitsy negotiations, with bilateral trade agreements, concessions and the establishment of small territory ground rules which will not necessarily be to our advantage in the context of Brexit. It must be recognised that the best outcome for us is the retention of what we have, warts and all, namely, access to markets in the United Kingdom and the rest of the European Union. Brexit will have major implications that were not thought out. I anticipated that there would be a Brexit. There have been some developments globally in the past year or two that were against the run of play and for which there does not appear to be a logical explanation and we may see more. Logic does not enter into it. However, we are in the business of survival. We have to do what is necessary to ensure that, as a nation and a country, we will survive to the best of our ability.

Chairman

There are many questions for the delegates. Deputy Kate O'Connell spoke specifically about delivery delays and timelines in drug importation. The delegates might deal with that issue first.

Mr. Muiris O'Connor

I will ask Mr. Goodman to address it.

Mr. Fergal Goodman

I concur with Deputy Kate O'Connell on the issue of the supply of drugs and medicines. It is one about which we are concerned and it has been identified by both the HSE and the Health Products Regulatory Authority, HPRA. Ireland is a small market. There are a number of risks, one of which is that products are packaged and labelled for use in Ireland, the United Kingdom and Malta, countries in which English is spoken. A common supply chain is operated. If the United Kingdom was to be carved off, potentially we could find that we would no longer be part of the bigger supply chain that would include the United Kingdom, leaving aside the trade issues of the speed of delivery. When we hit a medicines shortage, we can bring in product quickly. I am sure the Deputy knows much more about the practicalities than I do. We can do that currently, but in a Brexit scenario it would be significantly threatened, as Deputy Bernard J. Durkan mentioned. The HPRA is part of a heads of medicine agency network. It is also involved on the board of the European Medicines Agency, which is the regulator. We have identified the difficulty presented by this issue. There is not and could not be a simple solution in a hard Brexit scenario. As such, we may have to look at a different supply route, whereby we would link with other markets in which we might be able to access supplies speedily. However, we are still at the point of identifying all of the challenges, following which, together with other colleagues internationally, we will plan to avail of the available options to work around them. As is apparent from the list of issues we identified, many of which were echoed by members, we did not identify every issue on what is a long list. All of the ones Deputies and Senators have raised are ones of which we are aware. We will move from identifying issues to quantifying them and scenario planning to determine what the options are, including what nobody had thought of previously or had to engage with because for most of our working lives we have operated within the EU domain. As there is none in place, we have to devise alternatives but in collaboration with our European colleagues.

I do not know what the United Kingdom's plans are, but we have noted that the EMA will have to relocate from London. It has already been signalled by the pharamceutical industry in the United Kingdom that this is a big concern for it. The Japanese pharmaceutical industry has also expressed concern that the EMA will have to relocate from the United Kingdom because that is where it is plugged in. It is one of the consequences that may not have been contemplated when votes were being cast and debates were being had in the United Kingdom. Internationally, everyone is waiting to see what proposition the United Kingdom will make in this respect when it moves into the negotiations. There will be issues and sub-issues all the way down in every sector. The United Kingdom has not put into the public domain what its analysis is or how it wants to proceed. We are all waiting to see how it plans to move forward.

On the issue of recognition of persons who have trained in the United Kingdom, as it happens, the Pharmaceutical Society of Ireland is one of the bodies with which I have a working relationship in the Department. It has identified this issue as a key concern. It operates a registration programme for pharmacists from non-EU and non-EEA countries, whereby applicants must successfully complete all stages of a third country qualification recognition process. It is much more onerous than automatic recognition.

Deputy Kate O'Connell

In the past I took on a student from China. The process is hugely onerous and while the language barrier is one problem, there are other issues involved.

This girl was highly qualified and to my mind was fully suitable to do the job. I did the process and it is a completely different ball game getting one's certificate from the pharmacy society in the United Kingdom, coming here, essentially getting a form stamped and turning up on a day. That would mean going through the entire internship programme, which used to be called the pre-registration process. It is a complete departure. Essentially, it is retraining after one's degree. It is very serious.

Mr. Fergal Goodman

I am just saying that as of now, that is the alternative to the automatic process. Deputy Durkan spoke about the risk of us scurrying off and looking at many individual bilateral arrangements. We can scheme up what might be necessary. Senator Dolan adverted to a whole-of-Government approach and the fact that the Department of the Taoiseach is the lead organisation when it comes to policy and the Government's strategy on and approach to Brexit, and that that belongs within the whole-of-EU approach. We do not have licence to engage on some kind of bilateral basis. We can work up ideas as to what we might do if we end up moving into that space, but that is not what we have authority to do at the moment. I would imagine it is not the Government's policy across all sectors that we would break out and start to try to do things individually.

Chairman

Will the negotiating stance be that the 26 countries should negotiate with the UK? Will it be a common negotiating stance?

Mr. Muiris O'Connor

Ireland will be negotiating as one of 27 countries of the EU.

Chairman

We will not negotiate with the UK.

Mr. Muiris O'Connor

It is explicitly forbidden among the remaining 27 countries to-----

Chairman

We can put an emphasis on our particular relationship with the UK regarding all the issues, not just medical issues.

Mr. Muiris O'Connor

Yes, exactly. There is a task force set up under Mr. Barnier that will represent all 27 member states. That is the pinnacle of the negotiating apparatus for the EU. To date, it has identified four key priorities, one of which is the Good Friday Agreement and the North-South peace arrangements. That is a demonstration of early success in influencing the broader EU negotiating position.

We share Deputy Durkan's wariness about bilateral arrangements. On the other hand, we have routine, deep relations with the UK and in terms of North-South bodies. The full management team of the Department of Health met the full management team of the Department of Health in the North in January to discuss a range of issues, one of which was Brexit. We will continue to meet biannually, not to engage in bilateral negotiations. That is to collectively deepen our appreciation of the challenges and, as is clear, it remains to be seen what specific objectives the UK will bring to the negotiating table around this area. There is quite a bit of other-----

Chairman

Before we conclude, the Brexit negotiations have not started. This is our first meeting with the witnesses in regard to Brexit. Hopefully, there is a possibility that we can ask them to appear again once the negotiations have started to see if we can clarify some issues which could not be clarified today.

Senator Colm Burke

On the issue of people going abroad for medical treatment, my understanding, and I cross-checked this before asking the question, is that if someone is a VHI patient they can go to the UK and get treatment if the treatment is not available here. Is there a need to contact our insurers to see if they have given cover for treatments abroad where the treatment abroad fund would not have been aware of that? That is why I believe the figure of 24 for inpatients is very low and I do not believe it is a true reflection of the actual numbers.

Mr. Fergal Goodman

With regard to the schemes we refer to, namely, the treatment abroad scheme and the cross-border directive, the reason we tabled those as issues of concern is because those derive from EU legislation. I imagine that insurer-to-provider arrangements across the Irish Sea are not part of the international agreements at EU level that provide for that but I take the Senator's point that there is-----

Senator Colm Burke

I am saying that because of sub-specialisation there is a reliance by Ireland on the UK for particular treatments, and that would include private patients.

Mr. Fergal Goodman

Yes. It is another consideration in terms of people's ability to access the service but just through a different route.

Chairman

Mr. O'Connor might take two or three minutes to wrap up.

Mr. Muiris O'Connor

Deputy O'Connell and Senator Colm Burke raised issues about the recognition of qualifications and the extensive reliance we have on the UK higher education system for certain qualifications. That is a matter we are very live to and one that is very high on our risk register. Ireland is disproportionately reliant on the UK higher education system, particularly for specialist postgraduate programmes, and the health sector is particularly reliant on that across various sectors.

In terms of the training bodies with the UK, there is a complexity in that regard. It is a bit like the bilaterals. It is not sufficient for us to engage with and agree equivalences with the UK because as part of a bloc of 27 other countries, it is a broader negotiation. However, when the negotiations get under way we are confident that our close relations with the UK will be utilised by the broader European side in ensuring a maximum of alignment. The UK would be very alert to that because it has a huge reliance on EU nationals in its health workforce. I do not want to say I am hopeful but there is a shared interest on both sides in that regard.

As a general point, the Department is working with much more detail than it was possible to bring to bear on the material supplied today such as the opening statement and so on. In advance of negotiations it would not be appropriate to divulge much of the detail but in terms of the details requested here on service level agreements, SLAs, and so on, we will look at that.

Senator Dolan captured very well the live nature of the process and the amount of contingency planning that has been done. In fact, it is almost all contingency planning. There is nothing that is not contingency because the UK's position is so unclear.

Senator Dolan also captured well the extent to which health is part of a bigger discussion. We probably made the apparatus and the arrangements sound complicated but they are quite streamlined within the Department and interdepartmentally and we may not have done them justice here today.

The national priorities have been set out and they relate to issues of economics, trade, customs and borders. It is clear in any of the health issues that those broader issues of customs, borders and trade will have huge and direct implications for the challenges we will be navigating on the health side.

Chairman

I thank Mr. O'Connor.

Mr. Muiris O'Connor

There was a question on retirees and pensioners.

Mr. Fergal Goodman

It might be important to touch on that question. A substantial number of people have retired from the UK to Ireland. Approximately half a million UK pensioners reside in other EU countries, of whom approximately 130,000 reside in Ireland. A similar number reside in Spain, and others reside in Italy and France. We are a big feature in that regard and there are reciprocal arrangements in place for Irish pensioners in the UK. The agreement between us provides for provision of health care. In effect, a medical card is provided in Ireland without any assessment process of those UK pensioners on the basis that that is what they would be entitled to in the country where they paid their social security contributions and so on.

If there was an exiting process with no follow-on arrangements, we would have to subject those pensioners to a medical card assessment process. That would be an administrative process. We believe many of them would qualify for a medical card anyway but it is much more streamlined at the moment because there is no requirement. Once somebody is a UK pensioner, they get a medical card and there are no issues and no questions asked.

Senator Colm Burke

That is because of the reciprocal arrangement at the moment.

Mr. Fergal Goodman

Exactly.

Senator Colm Burke

Would that reciprocal arrangement stay in place post Brexit?

Mr. Fergal Goodman

I think it comes into the basket of "we would very much like it to". We must see the nature of the UK-EU relationship after the event.

Deputy Kate O'Connell

I am a great one for finding a silver lining. We are an English-speaking country. Is there a positive there? Have the witnesses seen any evidence of positives where we might become a destination for research because we will be within the EU and, therefore, EU funding will probably be channelled here more than to the UK so our universities and standards could benefit? In the long run, we could come out of this very well from a pharmaceutical point of view because we have such a good international reputation for making and developing stuff and producing good graduates. Have the witnesses seen any positive moves towards that sort of thing? Are they anything other than notions I might have? Are there positive moves from academic centres and research institutes to have a look at Ireland because it is an English-speaking country with a very good workforce? Are soundings like these coming through or not?

Mr. Muiris O'Connor

In any change scenario, there are risks and opportunities. I am afraid that on this occasion, the risks appear to outweigh the opportunities. The European Medicines Agency is a very significant opportunity. We are one of a number of countries that are preparing bids to have it located there. We feel we have a very strong case, much of which has been articulated by Deputy O'Connell, such as the industry base we have, the university base, the fact we are English speaking and the minimisation of the disruption for the existing staff in London. That would be a huge boost to the industry, to Ireland's reputation more generally and to the wider economy.

Research is the other area that emerges as one of potential opportunity. This was not strong in the discourse before the Brexit referendum but the UK is a huge beneficiary of EU research funding because of the strength of its university base. There is a lot of concern in the UK about the absence of Horizon 2020, not just for funding but for the international collaborations and global standards in which the UK can aspire to lead. The Department of Education and Skills would lead on this but we work very closely with it in identifying opportunities in health and matters like joint professorships. Such things are being explored as part of the planning around that to see if we can attract some of the key researchers to Ireland.

Chairman

I thank Mr. Monks, Mr. Goodman, Mr. O'Connor, Mr. Smyth and Ms Flynn for updating us on the preparations for our Brexit negotiations on health matters. I suspect we will be asking them to appear before us some time in the future to give us an update. We will now go into private session to prepare for a meeting at 5.30 p.m. concerning the UN special rapporteur.

The joint committee went into private session at 3.55 p.m. and resumed in public session at 5.30 p.m.