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JOINT COMMITTEE ON THE IMPLEMENTATION OF THE GOOD FRIDAY AGREEMENT debate -
Thursday, 3 Jun 2010

Cross-Border Co-operation: Discussion with Co-operation and Working Together

We move to our main item of the day. It is a great pleasure to give a warm welcome the members of the Co-operation and Working Together organisation, CAWT, in particular, Mr. Colm Donaghy, director general, whom I met earlier, Mrs. Bernie McCrory, the chief officer and Mr. Tom Daly of the management board. All are very welcome and it is a great honour to have the delegates here.

The Co-operation and Working Together organisation is a cross-Border partnership, formed in 1992 to improve the health and social well-being of people living in the Border regions. I have had occasion to collaborate and interact with these people at meetings in Northern Ireland and was always impressed by them. Senior representatives from the CAWT partner organisations are members of cross-Border strategy groups which guide strategy and integrate cross-Border work in six service areas: acute hospital services; mental health; disability; population health; primary care; and older people' and children's services. CAWT has been funded from HSE resources, the Northern Ireland health boards and trusts and has been benefited from support under previous INTERREG and peace programmes, which we totally support.

For the period 2007-2013 a total of 12 cross-Border CAWT projects will be supported under INTERREG 4A, with a combined value of some €30 million. Many members of this committee live in Border areas. We have a keen interest in supporting cross-Border work which leads to economies of scale and avoids duplication, benefiting people on both sides of the Border.

Members of the committee are reminded of the long-standing parliamentary practice, or longstanding rule of the Chair, that members should not comment on, criticise or make charges against a person outside the Houses, or an official either by name or in such as way as to make him or her identifiable.

By virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of the evidence to this committee. If you are directed by the committee to cease giving evidence in relation to a particular matter and you continue to so do, you are entitled thereafter only to a qualified privilege in respect of your evidence. You are directed that only evidence connected with the subject matter of these proceedings is to be given and you are asked to respect the parliamentary practice to the effect that, where possible, you should not criticise or make charges against any person or persons or entity by name or in such a way as to make him, her or it identifiable.

I invite Mr. Donaghy to speak about the specific projects in which CAWT has been involved to date and to outline its plans for the future to improve the health and well-being of Border communities.

Mr. Colm Donaghy

Thank you. We are delighted to be here today and to have the opportunity to speak to the committee. I wish to give a brief run-through of perhaps ten minutes, giving the background to CAWT, its rationale and how we are moving forward. I hope members have copies of Powerpoint slides in front of them and I shall run through these quickly to give a flavour of CAWT.

By way of context, members will see there is a shaded area on those slides which indicates the area CAWT covers, namely, about one-third of the landmass of the island of Ireland. The rationale for CAWT is that we believe the further one is from the seat of Government, whether in Belfast or Dublin, the more one suffers in terms of peripherality and infrastructure. Part of the rationale for CAWT was to come together to see if we could pool resources and examine how we might improve the health of the population in the Border area.

As the Chairman stated, it is a partnership, primarily a virtual one. So, although I am director general of CAWT I also work in the health service in the North and serve in CAWT on a voluntary basis, as does Mr. Daly. Mrs. McCrory, our chief officer, works full-time in the CAWT development centre.

Some 1.6 million residents live in the area covered by CAWT. We have a common demography. Some of the research we have carried out indicates that the demography is very similar in terms of the aging population, disabilities and some of the disadvantages the population of the area has, on both sides of the Border. The critical mass of that population allows us to take forward a number of the operational projects we have on the ground and shows where it makes sense for us to co-operate on behalf of and for the benefit of the population in the Border area.

As a partnership CAWT has benefited in recent years from EU funding, INTERREG 3 and, lately, INTERREG 4A. Later in the presentation I will highlight some of the projects that have been funded by the latest INTERREG 4A funding and will give an indication of some of the projects which were funded previously through INTERREG. One thing I always say is that CAWT predated this. It was established in 1992, predated European funding and will post-date it in terms of the co-operation we have along the Border corridor.

I also highlight that, through INTERREG and European funding, CAWT's remit is wider than just the Border area. It covers all the North, excluding Belfast and those areas shaded in the map which relate to the southern side of the Border. Therefore, the learning from the projects we have on the ground is wider and I shall touch on some of that as we go along.

The lead partner in terms of European funding in INTERREG 4A is the Department of Health, Social Services and Public Safety. The project partner is the Department of Health and Children. So, while CAWT is implementing the INTERREG projects it does that on behalf of the two Departments, the HSE and the organisations in the North. The projects are synonymous with the strategies of both Departments and with the strategies of the organisations that straddle the Border.

With regard to how CAWT is organised, it has a management board, but it is a virtual management board because its members have other jobs as well. CAWT also has a secretariat, which is made up of people from the organisations who are, if one likes, a conduit into those organisations for each of the partners for easy access to information and analysis. We also have a CAWT development centre, led by Bernie McCrory, where approximately 12 people are employed. Obviously, with INTERREG 4A and the funding for that, we also have quite a number of projects on the ground. Therefore, for a temporary period we second other members of staff, primarily from within the HSE and the health and social care organisations north of the Border, to do that project work on a time limited basis. A tremendous amount of work also goes on over and above project work with regard to co-operation North and South from all of those organisations.

The business case we put to the Special EU Programmes Body, SEUPB, was a closed call for European funding. The closed call was to the two departments, the HSE in the South and the Western and Southern Health and Social Care Trusts in the North, and related to the funding available under INTERREG 4A. As mentioned already, the two departments asked CAWT to facilitate the work on that. As a result, we have 12 projects at different stages on the ground. Some are already up and running and others will be up and running in the near future. These projects cover a wide range of areas. They are: an acute hospital services project; a project on clinics for sexually transmitted infections; the development of eating disorder services; a project on multilevel alcohol harm reduction; a project called Turning the Curve which supports people with autism; a project on improving outcomes for children and families; support for older people; preventing and managing obesity; support for people with disability; tackling social exclusion and health inequalities; tackling diabetes in high risk clients; and workforce mobility. These are the projects on which the €30 million provided by INTERREG 4A to the two departments is being spent.

I have already touched briefly on the process of accessing the funding. The two Departments, through CAWT, engage widely with the stakeholders in both areas. The 12 projects have resulted from the priorities indicated by local people and those identified by both departments. These decided they were the priority areas on which we needed to focus and in which to invest. The closed call to the SEUPB was approved by both Ministers in June 2009. Following their approval, we have gone ahead to recruit to the projects and to set up all of the project management responsibility aspects of the projects.

One of the biggest and essential tasks for the future is to meet the European Union targets in terms of the profile of expenditure. We must also ensure that the projects we put on the ground have a real benefit for patients and clients. The evaluation we will carry out will indicate the projects we believe have been successful. The funding ceases in 2013 and the big challenge for us over the next two to three years will be to ensure we can mainstream or sustain the projects beyond the European funding. The partners in CAWT will be instrumental in ensuring we can do that. We already have commitments to the funding of some of the projects and we will work over the next couple of years with our partners and both departments to ensure the projects proven to be of benefit will be funded in the longer term.

On the issue of embedding cross-Border collaboration at a policy and health service level after the EU funding ends, while our current focus is very project orientated in terms of INTERREG 4A, we are conscious we need to ensure we learn from each other as we move forward. We have strategy groups who sit alongside the European funding and these groups generate new ideas and ways of co-operating and ensuring we can improve the health of the population in the Border area, over and above European funding. The members of the strategy groups are people who work in the service North and South.

I thank Mr. Donaghy for his excellent presentation and detailed account of CAWT's evolution and activities.

I welcome the representatives of CAWT. This is not the first time I have heard one of their presentations and today's presentation was equally as good as one I heard at a conference in Derry on the issue of health. Illness and health issues know no borders. Whether one is in the North or South, when sick we face the same dilemmas in terms of accessing services and obtaining high level care and proper treatment. Through the work of CAWT, we are sharing ideas on best practice and what is necessary. We have much to share and to learn from each other. That sharing and learning will bring improvements. It is a given that we must get and provide best value for money. If we are in a position to share and benefit from the experience North and South, we can ensure we get value for money. Nobody has a monopoly on knowledge and the knowledge each of us has in the medical area is valuable and must be taken into consideration.

I come from the Border constituency of Cavan-Monaghan and am aware of some of the excellent services being developed through CAWT. In Monaghan hospital the ear, nose and throat service works extremely well, despite the attempts made in the media to play it down and negate the good work being done. Tremendous work is being done there and many people, North and South, benefit from shared services without which they would be on waiting lists for God knows how long and would certainly not be put first. It is a bugbear of mine that people who are ill, whether North or South, should be able to access the nearest service to them appropriate to their medical need. We talk about centres of excellence. I have no difficulty with having centres of excellence and if people have a serious condition, they should go where they will get the best service available to get the best possible outcome. However, in cases where people could be treated for an illness as close to home as possible, the Border should not be an issue. Speakers mentioned the pilot GP out-of-hour service located in Castleblayney. I know from experience and from speaking to people how well that service works.

With regard to the areas CAWT proposes to consider and the programmes in which it is involved, I have two questions. Speakers referred to an eating disorder project, alcohol harm reduction, reduction of self harm and sexual health services. These are services where we need early intervention and need to get information to young people and make them aware of the dangers. We also need to show them how to deal with and cope with peer pressure. Has CAWT plans in that regard or does it engage with the education Departments, North and South, in the roll-out of their service to ensure it gets to the target market? With regard to the eating disorder project, I understand four pilot sites were to be identified along the Border region. Have those sites been identified? With regard to the work being done in the area of autism, I am aware of the facility in Middletown and of the difficulties there were. However, the project seems to be moving on and will be hugely important for the Border region. Is CAWT involved in that?

Dr. Alasdair McDonnell, MLA, MP

I thank our visitors for their presentation. My question is broadly simple, but at the same time may not be so simple. What obstacles have been identified to free access because ultimately, we have to set down our objective and the end point? The end point for me is to ensure that a patient living, dare I say to Mark Durcan, in Buncrana, can access Altnagelvin, or somebody living in the Cooley peninsula can access Newry or equally, somebody living in Keady or wherever in Armagh, can access Monaghan county facilities. This would mean that people in those Border areas could move fairly freely. We need to hear what is needed politically to move this on. The people I listen to and talk to — I recognise some tremendous work has been done — tend to see the delegation's work as something of a Cinderella effort that works within public health. The vast majority of health care operates within primary care. At what point will it be possible for a patient in the Border lands, for instance, in Donegal, to access a GP service in Derry or similarly, around Newry? Tertiary-level services are available in the North and I do not get an impression there is a major ability to access those services. I think of my own doorstep and Mark Durcan made a major effort in getting a cancer centre built in Belfast City Hospital. At what point will people in north Louth or in east Donegal be able, freely and as an option, to access the world class cancer service in Belfast?

I mean no disrespect to the service in Dublin but I refer to third level services and the likes of renal dialysis and other tertiary level services. For the man in the street, the sense is that we will not have achieved very much until we achieve ready and easy access to services, in other words, the establishment of an exchange rate mechanism of some sort, a notional charge for a day in hospital in either the North or South and a notional charge for this bit or that bit. These exchange rates could be charged easily enough. Until we get to that level, the man or woman in the street will see little or no benefit and while good work is being done, much of the co-operation will be perceived as something abstract and elitist.

I join in the welcome to the representatives of CAWT. I will preface my remarks by saying that sometimes the business of the Dáil or Seanad Chamber can impact upon the attendance at the committee. I am very conscious on occasion it might appear to visitors that there is not the interest they would have expected but it is important to explain there was a number of distractions, for the want of a better word, this morning and I have no doubt that colleagues of all opinion, particularly across the areas addressed by CAWT, would have a shared interest in its work.

I also welcome the expansion of issues addressed by CAWT. In the early years, going back to my time as a member of the North-Eastern Health Board, we had two health boards and two health areas north of the Border. It was in the very early stages and it was a bold step unquestionably by the various executives involved, at a time when discourse was not at all as it is today and I acknowledge that. I am not offering a criticism of any member of the delegation or collectively, when I say that I would have hoped, even going back to those days, as a member of the health board, that progress in terms of co-operation in health care delivery, North-South, would have reached a more advanced point at this stage. I expect the delegation would accept this is a fair comment and that delegates share the hope that we will be able to expedite the delivery of not only the list of projects up to 2013 outlined by the delegation but that it would build even more bold steps in the future, to the benefit of everybody.

The first of the current 12 points of focus is the acute hospital services. I ask the delegation to speak about the extension of acute hospital services and co-operation in terms of North-South delivery to patients. I am a Cavan-Monaghan Deputy, although I am also a spokesperson on health and children. I tend to think only, perhaps, in terms of ENT, ear, nose and throat and the relationship between Omagh and Monaghan that has been in situ now from Mr. Babu’s time and continuing. I ask for elaboration on that area because this is where it is at, so to speak. If we can talk in real terms about acute hospital cross-Border delivery systems, this is where we want to get to, from the early explorative initiatives on out-of-hours GP co-operation in Castleblayney, Keady, Inishowen and Altnagelvin.

How is the work of CAWT affected and how might it be affected by signalled cutbacks in health funding North and South? Has there been a direct impact with regard to its work programme and the development of various projects? Is the delegation aware that only yesterday, the Health Service Executive indicated that over the period from the end of June, from 28 June and into July, there will be three tranches of suspended periods of service delivery at Cavan and Monaghan hospitals, including ENT, to a total of 29 working days over that two month period? This is, sadly, an annual announcement, due to the current staff embargo and the inability of the system to recruit temporary cover staff for holiday arrangements.

With regard to the elective health care needs of people, health care cannot be turned on like a water tap. People need 365 days a year access to health care provision. I am deeply concerned that we are now looking at 29 days, which by any measure, is a month out of that two month chunk, in which we will not see the ENT provision, along with a whole range of other elective opportunities and the suspension of out-patient department clinics. It is a very worrying situation.

I notice the bells are ringing for a vote in the Dáil. I will make one further point of concern. With regard to particular operative procedure access in this State, the measurement is the potential throughput by population. I have recently represented a family with a child for whom the particular requirements were not available either here in this State or in the northern State and the child had to be brought to London, to Great Ormond Street, for an operation. In my inquiries, I am trying to establish the procedural needs of the population on the island of Ireland that could be provided for if we looked sanely and sensibly at the numbers of people on the island of Ireland, rather than looking at two separate back-to-back population entities. Could CAWT comment on that? Has it carried out any research on it? Thankfully the child in that instance has done well. I am deeply concerned about that. I have other questions, but I appreciate that the clock will beat me.

Our next speaker will be Ms Margaret Ritchie, MP, MLA, leader of the SDLP. I shall ask Senator Keaveney to take the chair in our absence and allow the remaining speakers to continue. We hope to return then to join you all and complete the business.

Senator Cecilia Keaveney took the Chair.

Ms Margaret Ritchie, MLA, MP

I thank Mr. Donaghy and his colleagues for their in-depth presentation, which shows us that work is going on. For us this is about the physical outworkings of the Good Friday Agreement. I am looking for some statistics on the effectiveness. Mr. Donaghy has detailed various projects that are working on a cross-Border basis in terms of health and medical and social care provision. Has CAWT carried out any evaluation of the effectiveness of those projects and their reach within those Border communities?

Deputies Blaney and McHugh were scheduled to speak next followed by me. However, I shall now call Mr. Mark Durkan, MP, MLA.

Mr. Mark Durkan, MLA, MP

I join others in welcoming Mr. Donaghy and his colleagues. As someone who sat on the Western Health and Social Services Council for most of the 1990s, I am very familiar with the developing work of CAWT then. I acknowledge the path-finding work that was undertaken then by Tom Frawley, Donal O'Shea and all of their colleagues. It is clear CAWT is continuing to try to find paths forward on a number of levels. Where CAWT has ended up being able to utilise EU moneys, I am conscious that in the past those EU moneys tended to be available for projects and initiatives in the area of public health as mentioned by Dr. McDonnell. However, under the Lisbon treaty Europe now has a wider competence in health funding. So for the first time European money can technically be applied to direct health service provision, which was not the case in the past. Obviously EU budgets will be constrained over time as all budgets are. We, as policy makers, need to be conscious that the permissibility of EU funding for health has broadened and we need to gear up our thinking in that regard. I would like to follow through on some of the questions Dr. McDonnell raised about how we might make this co-operation even more meaningful in the provision of direct health services.

That is not to decry the value of the work CAWT has done, not just in health terms, but in producing some positive multipliers in respect of other public policy interests. For instance, I know of some of the work that has been undertaken in the past in the area of social inclusion and addressing health inequalities. I have taken part in some conferences and events in that regard. I was very struck by work that was undertaken with Traveller women. The result of those initiatives was to make people much more engaged and actively interested in their own health and much more aware of health challenges for the families. It resulted in a motivation that expressed itself in a Traveller woman expressing the aspiration that a daughter of hers might become a doctor or a nurse. It was a completely different take on things. Everybody present was really taken by this declaration. So it shows it is not just within the strict confines of health policy that we can get results and benefits from this sort of co-operation. We can also get considerable lateral policy benefits.

I refer to the goals Mr. Donaghy mentioned, which are reflected in the second last slide. The goal of sustainability and mainstreaming and the goal of embedding cross-Border collaboration at the policy level are very good goals to have, but are hard to achieve. They will be particularly hard where budget constraints North and South will make Departments look inwardly much more and may feel compelled to prioritise in a fairly selective way. They might regard some of the CAWT initiatives as discretionary optional extras. How do we sustain and mainstream these sorts of projects in the changing EU funding environment and the in the evermore constrained funding environment North and South? Should we consider creating some dedicated cross-Border funding streams that can include health and social care — almost like our own version of EU Structural Funds — so that funds are already in existence for which the health authorities related agencies North and South can bid and plan? We will not embed and mainstream if the people who are currently involved in CAWT find themselves having to busk around the different budget lines, under pressure in the North and the South. How do we embed things at a policy level in such circumstances?

There is a report pointing out a number of challenges and opportunities in respect of health matters North and South, which is barely acknowledged by the Minister for Health Social Services and Public Safety in the North. At a recent meeting of the Northern Ireland Assembly committee it was regarded as quite awkward as to whether somebody giving evidence at the committee could admit that he or she knew of the report's existence or the extent of the recommendations. While the ambition about embedding is important and I would encourage it, we need to be frank about some of the impediments.

I apologise for the constant flux, but that is the reality here, unfortunately. The delegates might have dealt with some of these issues earlier. CAWT has been extremely effective. It has delivered services and made sense of health delivery in a number of initiatives. Coming from Inishowen, sometimes we cannot understand how other people cannot work it out. It has been one of the better examples of cross-Border co-operation in circumstances where other people seem to be stuck for good examples of cross-Border co-operation.

The GP out-of-hours service has been very good, but perhaps not advertised well enough. CAWT has been addressing it recently. I am interested in how the person who has recently moved out from, for example, Derry and maintained a doctor in Derry is impacting on our numbers. There is a major issue regarding habitual residency requirements and the reality of two jurisdictions while at the same time people regard Donegal as a suburb of Derry.

It is very important that people be as up front as possible in saying where cancer and renal services are happening and how they will happen. We need to embrace the many different communities that are campaigning to sell equality and equity. There is medical politics over the location and there is also an element of concern that if it is seen to be driven only on one side, the equality of access becomes aspirational rather than real.

The entire north west and the Border counties — in short Ulster — have been through the Troubles. There is research on sexual violence, post-traumatic stress and other mental health issues. Many of these issues are stronger in post-conflict areas, or areas of current conflict, than they are in other areas. I wonder if CAWT is doing much with creative therapies, such as music therapy and art therapy. Is it trying to approach those issues from a different perspective? One of the realities in the North is that music therapy is a recognised profession. One gets paid as a professional there, but it is not one of the recognised professions in the Republic. Can CAWT do anything to help to push the door of recognition, so that these things take place? Music therapy might sound superfluous in the context of the main issues, but when one does some research one finds it is quite a central issue.

Although I could speak forever about health issues, I will not speak for much longer. I congratulate those involved in the sexual assault treatment unit in Letterkenny. There was an aspiration to maximise co-operation in Antrim. Most of this work is geared around health, but it has a justice element as well in so far as it relates to pursuing the perpetrators of crimes. There is co-operation between the PSNI and the Garda, as well as between CAWT and the health services, on many issues. I suppose the question is whether there is enough co-operation between the legal, judicial and health services, as one entity.

I apologise for the interruption, which was caused by votes in the Seanad. I was also asked to attend another committee for a quorum. I missed the CAWT presentation. I have seen the written presentation. I refer to the briefing notes that are in front of us. I commend the fantastic work CAWT has done on health co-operation between North and South. I agree with Deputy Ó Caoláin that we all hoped we would be further along this road at this point. The realities are sometimes very different. At least we are on the right road and moving in the right direction.

I welcome the expansion of the areas in which CAWT is involved. I have a number of brief questions. The delegates have outlined the funded programmes that CAWT is involved in delivering on the ground. Would CAWT like to be further involved in other areas? Is there is need for more co-operation between North and South to make that happen? Is there political willingness on both sides of the Border to move down this road at a quicker pace? Would the political resolution of two or three items make the work of CAWT easier or better? More importantly, would such developments deliver better health services on an island-wide basis?

Many other questions have been raised. I will not repeat those points. I would like to speak about cancer services in the north west, specifically the new radiotherapy services that are to be developed in Altnagelvin, County Derry. CAWT's 2009 annual report suggests that the relevant facility should be operational in 2015. Various dates have been mentioned over recent years. The most recent date to be mentioned was 2016 or 2017. Do the delegates believe the target date of 2015, which is mentioned in the annual report, is accurate? Are we still on track to meet that date? It is important to ensure it is an all-Ireland facility, rather than a facility located in Altnagelvin with services being bought from the South. I commend CAWT on the work it has done to facilitate this development in the first instance. Many research studies were done and many statistics were used to make the case for an all-Ireland radiotherapy centre in the north west. It probably leads back to the question Deputy Ó Caoláin asked. If we use the same approach, can facilities, operations and services be provided in other areas? Can we allow patients to access services in close proximity to them or, in the case that has been mentioned, within the island of Ireland?

Deputy Noel Treacy resumed the Chair.

I welcome the CAWT deputation. I particularly welcome my colleague from County Donegal, Mr. Tom Daly. I would have a good word for him from his day in the former North Western Health Board, of which I was a member. Like other speakers, I welcome the work that has been done by CAWT over recent years in the area of health development.

Dr. McDonnell mentioned the cancer services provided at Belfast General Hospital. We might take that one first. There have been developments there. There is co-operation between North and South. The direction is good. I am surprised and annoyed by the uptake of the service provided at Belfast General Hospital on the part of patients in the South, particularly those in Letterkenny General Hospital. I do not know if this is CAWT's area. I suggest that patients are not sharing the enthusiasm of their peers at the hospital. Perhaps they are not being given proper direction in this regard. I do not know why there is such reluctance to send patients to Belfast. This area needs to be addressed. I am not sure whether CAWT can do that. It is certainly a good development from a cross-Border prospective.

Senator Doherty and others have mentioned that co-operation between Letterkenny and Altnagelvin on cancer services is in the pipeline. I am pleased about that. The overall issue of the provision of all services, including health services, on a cross-Border basis is particularly relevant in the north west. I am not having a go at anybody. I am speaking my own mind on this. There seems to be a policy issue within Northern Ireland, whereby matters that arise west of the Bann are considered in the Northern Ireland context only. That has led to an infrastructural deficit in recent years. In recent times, this committee has discussed infrastructural developments such as the motorway. We have found that the Government in this jurisdiction has to drive initiatives and fund cross-Border projects to get them moving. There needs to be a serious policy shift in Northern Ireland. I am not dictating to the authorities there. I do not have any input there. A serious shift in the direction of infrastructure policy would be welcome, particularly west of the Bann. We should not just consider those areas west of the Bann that are in Northern Ireland — we should consider the north west of the island of Ireland as a whole. If that happens, the whole area will develop much more prosperously, not just in health but in all areas.

I welcome the work of CAWT. It mentioned deprived areas in its presentation. Senator Keaveney knows all about that in Inishowen. There have been some good developments. The work of CAWT on GP out-of-hours services and other items has been mentioned already. I hope the work continues and CAWT goes from strength to strength. I share Senator Doherty's sentiments about the provision of cross-Border services at Altnagelvin, in conjunction with Letterkenny. I hope that takes place in 2015. I believe that is the target at the moment. I do not believe it has changed. That would be welcomed in the north west as a whole, not just in Altnagelvin but throughout the area.

I welcome the members of the delegation. I thank them for their ongoing positive and constructive work. I would like to make a few observations. It has been a difficult session this morning. It has been a bit disparate, to say the least. We do not know who said what, or when they said it. I hope I am not going over old ground. I will keep it brief. I caught the tail end of Deputy Blaney's contribution on radiotherapy services. Are we on time for 2015?

In relation to the National Treatment Purchase Fund, there is an issue in a county like Donegal. There has been a low take-up compared to other counties in Ireland. The fund was a natural model, in terms of what CAWT is trying to do. I refer to the provision of services in Ballykelly, for example. Do the delegates have an opinion on the reason for the low take-up of the services provided by the National Treatment Purchase Fund?

On the HSE model, a colleague from Culdaff, with whom Mr. Daly and Senator Keaveney will be familiar, is on the board of HSE west. He has argued that driving to Galway, which is in the Chairman's constituency, to discuss the city's water quality does not make sense.

It is a lovely place.

Is the Chairman referring to Culdaff or Galway?

I have been to both places.

In that respect, the CAWT model is more relevant than the HSE model in terms of membership. Is there a drive to have this model mainstreamed, North and South, rather than having a vast geographical spread?

On citizenship for people with disability, is CAWT in a position to pressure the Administrations, North and South, to meet their quota requirement for work placement for people with disabilities? I understand the quota in this jurisdiction is approximately 4%.

Letterkenny General Hospital requires an endocrinologist. CAWT is examining the issue of providing different acute services to serve the needs of the two jurisdictions. Is it planned to employ an endocrinologist at Letterkenny General Hospital, perhaps through a shared relationship with Altnagelvin Hospital in Derry? We hear a great deal about cross-Border plans. This type of model will work and we must drive this agenda. I hope it will meet our needs in the north-west.

Despite the busy morning, we have had ten speakers, many comments and some questions. I ask Mr. Donaghy and his colleagues to respond.

Mr. Colm Donaghy

We will try to do justice to the many questions we have been asked. The common theme running through many of them is how we will make more progress and what are some of the potential barriers to CAWT continuing to make progress in the Border area. In responding generally to these issues, I hope I will address a number of the questions.

To provide a context, the organisations that form CAWT work within a policy framework set by the two Governments. My day job is as chief executive of a trust in the North and my policy context is that I plan to provide care for people in my area. The same applies on the southern side of the Border. From a policy perspective, I do not have a remit or permission to plan for the population located in the north-east on the southern side of the Border. However, where it is sensible to co-operate for part of the population in the north-east, we will come together. To give an example, in developing renal services in Daisy Hill Hospital we decided it would be sensible to provide additional capacity for people in the north-east to avoid the need for them to travel further to Dublin. This additional capacity is paid for through a contract. In general terms, however, we cannot plan for populations beyond the Border.

All of this begs the question asked by Dr. McDonnell as to how one ensures free access to services on either side of the Border. This is a question for both Governments and Departments in terms of the policy context that would be required to allow such a development to take place. I will set out some of the practical barriers CAWT has identified. We found when we were establishing the GP out-of-hours service that the two jurisdictions have different charging policies for accessing GP services and different regulations for regulating the practitioners who provide GP out-of-hours services. Issues also arise with regard to indemnity for people who travel across the Border. What we were able to do, in a practical manner, was to influence policy such that we secured a temporary change to our GMS regulations in Northern Ireland to ensure people from the North could access services in the South and practitioners in the South could provide these services.

I will detail what happened in practice. Members will recall the Shipman case. Dr. McDonnell especially will be familiar with it. As a result of this case, GMS regulations in Northern Ireland were tightened to try to ensure there would not be a repeat of the case. However, no similar review took place in the South which meant the regulations in the North were much tighter. In the context of influencing policy CAWT was able to secure a relaxation to allow people in South Armagh to access the GP out-of-hours service in Castleblayney. This is an example of how a practical issue acted as a barrier to making projects work on the ground. We overcame this barrier. We also have a memorandum of understanding between the two ambulance services on accessing both jurisdictions. The larger barrier in the context of making more progress on free access to hospital services, North and South, is a policy matter at government level.

Members will be aware that CAWT was asked to help complete a feasibility study to identify areas where it makes sense to co-operate. Deputy Ó Caoláin asked for examples of such areas. We discussed the issue of eating disorders. We are sending young people to London to have eating and personality disorders treated because we do not have a facility on the island of Ireland to cope with demand for such services. It makes sense, therefore, that both jurisdictions co-operate on the issue. The feasibility study CAWT helped to complete is now with the two Departments. If the areas outlined in the study were to be progressed, it would begin to set a policy context and framework for the organisations working in the Border area and enable more progress to be made in health and care co-operation, which is a general theme I picked up in many of the questions.

Another theme in many of the questions was how the current economic climate will potentially impact on CAWT. At present, the organisation is probably in a fairly favourable position in that European funding has not been affected by the current round of cutbacks. The issue will be one of mainstreaming when the European funding runs out. My view, which is one shared by the management board, is that in times of constraint we have an even greater duty to collaborate to ensure we use our resources more effectively and pool resources to ensure they are used more efficiently. The economic constraints under which we will operate in future present an opportunity to ensure we co-operate even more closely and pool our resources to an even greater extent to ensure we deliver value for money for the services we provide. The next two or three years will be challenging in terms of ensuring sign-up, as it were, to mainstreaming.

On the point made by Ms Ritchie, in each of these projects we are doing a robust evaluation of the benefits they will provide for the population. If the Chairman wishes, we will share with the joint committee the evaluation CAWT carried out on the effectiveness of funding provided under the PEACE II and INTERREG III programmes.

We would be delighted to receive the evaluation.

Mr. Colm Donaghy

I assure members that the evaluation will be done in the context of the needs of our population and the benefits delivered by the projects we are implementing. If we find these projects are not delivering benefits, they will not continue. If, however, they are providing benefits, we will seek to apply pressure to have the funding mainstreamed. I will ask Mrs. Bernie McCrory and Mr. Tom Daly to address some of the detailed questions. Deputy Conlon, who is no longer present, asked questions on our co-operation with the Department of Education, on whether we are involved with the new autism centre at Middletown, on the detail on eating disorders, and on whether the four centres are up and running.

Deputy Conlon sends her apologies. She has gone to another meeting.

Mrs. Bernie McCrory

With regard to eating disorders, Deputy Conlon asked whether we had chosen the sites of the centres. With regard to the four CAWT areas, there will be a site or central point for each of the four partners. We are trying to have a multi-agency approach to all the projects, not just this one. Where other people have learning sets, we want to work with them. We do not want to reinvent the wheel. Education seems to be a very obvious focus for partnership. However, the centre in Middletown is not one with which we are engaged at this point. It is basically a new service on the ground working directly with the beneficiaries. It is a purely educational facility. It is aware of our work and we are aware of theirs.

Mr. Colm Donaghy

Deputy Ó Caoláin asked for more detail on the acute services projects. I will ask Mrs. McCrory to give a little more detail on this.

Mrs. Bernie McCrory

I will respond in respect of two different areas. In the HSE's Dublin north-east area, there was for approximately 12 years prior to this measure a relationship between the Cavan-Monaghan group of hospitals and Omagh. Unfortunately, Omagh does not have a high-dependency unit or intensive care unit, and there are no inpatient ENT beds. For geographical reasons, the management in the Dublin north east area asked me to try to arrange a relationship with the Southern Trust in Northern Ireland. It is easier to access. What we did was set up an outpatient and day-case service in Monaghan hospital, moving into Cavan.

In April of last year, we appointed a part-time consultant. He does seven sessions, primarily in Dublin north east, but he is contracted to the Southern Trust. We have also appointed a full-time consultant in the Southern Trust. We have brought the complement of ENT surgeons in this area up to six. All of the sub-specialties in ENT are catered for. Two of the consultants are now seeing Monaghan and Cavan patients and are about to start seeing Louth patients. Since their appointment, almost 3,000 patients have been seen for their first appointment.

I am conscious the Deputy said there may be closures. Consultations depend on one's outpatient status. Day-case patients will be treated in Monaghan, if suitable. It is as near to the domicile of the patient as we can make it. If the cases are more complex, the patients will be sent to Craigavon or Daisy Hill for their operations. If one area is downsizing a bit, the patients will still go across the Border. There have been approximately 700 patients in the Southern Trust seen within the same regime. With regard to the mainstream nature of that service, there is a commitment from the HSE Dublin north east to commit €400,000 beyond the life of that project.

With regard to urology in Deputy Ó Caoláin's area, we have invested in a number of pieces of equipment. Almost 100 patients have benefited from its use.

The vascular part of the acute service mainly involves a bilateral arrangement between the HSE west, and the Western Trust. There are several vascular surgeons already employed in the Western Trust. There are no vascular surgeons in the HSE west. It is a matter of getting the project up and running. If one has an aneurysm, it makes more sense to go to Altnagelvin, 25 minutes across the Border, than to Galway or Dublin. That is the plan.

The urology service in the west mainly involves a bilateral arrangement. We have just received clearance to appoint a new urologist. At this point, the complement of staff is one general surgeon with an interest in urology. Very shortly, we will put a second urologist on to the team, which will work back to back with the two urologists currently employed in Altnagelvin. People will be able to access the majority of urology procedures locally. There will be a team of specialist nurses in the area.

Mr. Colm Donaghy

There are a number of questions regarding the north-west cancer centre and on whether it will be delivered on time.

CAWT was asked by both Departments to facilitate a project related to the north-west radiotherapy service and access to Belfast City Hospital. We have done this. The case is now with the two Departments to make progress. I ask Mr. Daly to elaborate.

Mr. Tom Daly

The work that has taken place over the past eight or ten months has really been on the formulation of the business case. Several of us on the HSE side were directly involved in that work, including people from the national cancer programme. We still believe the target date of 2015 is feasible and it will obviously depend on a positive decision on the business case that has been completed.

Senator Doherty made a point about the service being established as a truly cross-Border service. The population catchment from Donegal, and perhaps from part of north Leitrim and north Sligo, is clearly important in terms of the viability of the centre at Altnagelvin. We envisage arrangements whereby there will be continuing involvement by people from our services in the planning and management of that service.

A few points were made on tertiary services, the mainstreaming of acute services and the significant question of access between jurisdictions. People may continue to keep an eye on the progress of the proposed EU directive on cross-border mobility for health care, which ran aground recently but which is still very much an aspiration of the European Parliament. It would clearly represent a very important framework in terms of the bigger picture of cross-border mobility of both patients and professionals. We have a great interest in this in that it could lead to some lowering of the barriers that arise for professionals moving from one jurisdiction to another to provide services.

With regard to mainstreaming, there are a few practical examples that demonstrate the value of initial projects. The oral and maxillofacial service for the north west is based in Altnagelvin. Its complement of consultants is based on the combined population catchments of Tyrone, Derry, Donegal, Sligo and Leitrim. Outreach services are provided in Letterkenny and Sligo from the Altnagelvin base. One reason the service is of great value is that it gave the north west a local service that it did not previously have access to. Altnagelvin has provided a sustained service that was very unlikely to survive in the city and which was most likely to be centralised to Belfast. It is a good practical working example. The service is working very well and all the care pathways have been worked out. It works in a seamless fashion. There are some other examples in place of those types of services where they just have become a part of the service configuration in the general area. I shall leave it at that.

Mr. Colm Donaghy

There are a few other detailed questions. Perhaps if I repeat them, Mrs. McCrory can deal with some of those. There was a question from Deputy McHugh about work placement for people with disabilities, and whether we can bring pressure to bear on the organisations in both jurisdictions. Actually, we all work in those organisations and while CAWT has a role in awareness, it does not extend to putting pressure on organisations to that extent, to get them to meet their disability requirements. We are all aware of the regulations imposed on all of us, but this is something we can raise with the CAWT management board, to make people more aware of how they are performing relative to those targets.

I shall allow Mrs McCrory to deal with the matter of the endocrinologist at Letterkenny.

Mrs. Bernie McCrory

As far as indirect funding is concerned, this is not one of the areas.  The three areas I have outlined as regards acute services per se, are the ones we are concentrating on. I cannot say there are intense discussions ongoing in all the areas of deficit between Letterkenny and Altnagelvin hospitals. We have strategic groups comprising front line staff, clinicians, nursing staff and people who know the service deficits – and they are getting together, routinely. They have met two or three times already and have identified very many areas. I am not sure whether endocrinology has been included, but I can raise this with them as something Deputy McHugh has an interest in. For example, in Dublin north-east again, we had a recent acute services strategy group, and one of the areas of deficit there was ophthalmology. There clearly is a requirement there. The Southern Trust is about to appoint two new ophthalmologists. Previously it would have been getting a service from Belfast, so there is an aspiration that Dublin north-east will fund one more. That means there will be quite a good team of three people, and an on-call service will not be needed. Through discussion and in trying to see where we can remodel the service, we are getting better services, but I shall certainly raise that with the strategy group. It is an important issue.

Mr. Colm Donaghy

Senator Keaveney raised a number of issues around sexual and domestic violence and the use of music therapy.

Mrs. Bernie McCrory

We have not thought of the use of music therapy in this context, although areas such as autism and so on could benefit from that. We are still in a position to shape how we do it. I can raise that. Obviously we are getting new ideas all the time on how we could expend this money, so I shall certainly raise the issue of autism.

It is not just for autism but also for sexual violence and the post-conflict situation, in getting people to talk about issues and exorcising themselves which is somewhat preventative in nature.

Mrs. Bernie McCrory

We are working very closely with community and voluntary groups. One of our partners is Derry Well Woman and as the Senator knows, this is doing enormously successful work. It is being integrated into some of our projects, so I believe it will be addressed in this measure, albeit, it was not a specific measure at the outset. However, we are picking up things all the time that might add value to it. Derry Well Woman is doing an enormous amount of work for us on that.

Mr. Colm Donaghy

Mr. Mark Durkan asked whether dedicated funding on a cross-Border basis might be helpful, and not unexpectedly, the answer is "Yes". It would be useful to have dedicated funding on a cross-Border basis. I am not sure whether there are any further detailed aspects that I or my two colleagues need to deal with, Chairman.

Mr. Tom Daly

There are one or two specific things we can come back to, for example, the matter raised by Deputy McHugh. We shall just take a look at the specific position in the north-west in relation to that. Certainly in both hospitals the arrangements are in place to avail of that scheme, but I am just not au fait with the numbers at present. However, we shall take a look at that and come back to the Deputy, separately.

That is grand. If there is any specific issue on which the guests want to respond to anyone, they should feel free, and perhaps let the committee have a copy, in the event.

Before we wind up I will just say that I totally support centres of excellence, particularly the cancer centre of excellence led by Professor Johnson and his team in Belfast. They are outstanding. We have to broaden the whole capacity of that to deliver right across all of Northern Ireland, into the Border counties. There is an opportunity to deal with obesity in children, perhaps, which is a big challenge right across the island. There is a capacity here, given that Northern Ireland could be very involved in that and we have a serious responsibility within this jurisdiction, too.

I have a great interest in the multi-level alcohol harm reduction programme and project in which the guests are involved. We have serious problems in this area right across this island. Perhaps we could have some interaction and collaboration with Northern Ireland on that. My final question is whether the guests have any dealing with the Depaul Trust in this whole situation. It is based in Belfast and obtained an international award this week for its work in this area. There could have been an OBE involved, as far as I know.

Ms Margaret Ritchie, MLA, MP

It emerged out of the Society of St. Vincent de Paul, and it provides housing and support services to those who are at risk.

I know people are under pressure of time and I want to thank all our guests for coming here today for a clear and formal presentation. We are deeply grateful to them for the clarity of their contributions. It is clear from the presentation that their organisation is playing a real and important contribution to the lives and well-being of all our citizens living in the Border region, and the well-being of society as a whole. We wish them well, and they should be assured of our support, that of all our political parties, members of the committee and the individual politicians. We shall do our utmost to ensure that resources are available, because we believe that on an all-island basis the area of health is the one in which we can do most for our people.

The leadership of the guests, their vision and strategies are critical for delivering the service to all the citizens on an equitable basis right across the island. I say this in the light of the point made earlier by Dr. Alasdair McDonnell as regards the barriers we have to eliminate to ensure that these objectives are achieved. On behalf of the committee and on my own behalf I wish the guests well in their important work. Be assured of our support into the future.

Is there any other business.

I have a query on something that was said about the cross-Border mobility issue being a matter for the European Parliament. Is there a value in having a meeting of the island's MEPs at some point on issues of an all-Ireland nature that have EU implications?

It is hoped to have a meeting in the autumn to which the Senator will be invited, along with all MPs in the North and probably MLAs as well, together with a large number of politicians from the South. Perhaps that is something we could discuss some time in October. That is our goal.

I am aware people have other commitments. I hope to assist them in meeting those commitments. We will now adjourn for lunch.

Could we move into private session?

The joint committee went into private session at 1.18 p.m. and adjourned at 1.25 p.m. sine die.
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