Joint Committee on the Implementation of the Good Friday Agreement díospóireacht -
Thursday, 10 Feb 2022

Engagement with Co-operation and Working Together

Chairman

Before we begin with our guests, who are very welcome, I offer my condolences and those of the committee to the family of former Deputy and Minister of State, Noel Treacy, who passed away recently. He was a former Cathaoirleach of this committee and, as the current Cathaoirleach, I extend our sincerest sympathies to his wife Mary, his children, Joan, Emer, Lisa and Rory, and all other members of his family.

On behalf of the committee, I welcome Bill Forbes, chief officer; Damien McCallion, director general; and Neil Guckian, deputy director general, Cooperation and Working Together, CAWT. I apologise for the delay in getting them in here.

I will read a notice on privilege, which I am sure they have heard before. The evidence of witnesses physically present or who give evidence from within the parliamentary precincts is protected pursuant to both the Constitution and statute by absolute privilege. However, witnesses and participants who are to give evidence from a location outside the parliamentary precincts are asked to note they may not benefit from the same level of immunity from legal proceedings as a witness giving evidence from within the parliamentary precincts and may consider it appropriate to take legal advice on this matter. Witnesses are also asked to note that only evidence connected with the subject matter of the proceedings should be given. They should respect directions given by the Chairman and 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 or otherwise engage in speech that might be regarded as damaging to that person's or entity's good name.

I invite Mr. McCallion to make his opening statement.

Mr. Damien McCallion

I thank the Chairman and committee members for the invitation to address them today. The purpose of this submission is to brief members on the operation of the Cooperation and Working Together Partnership. I am joined by my colleagues Mr. Neil Guckian, chief executive of the Western Health and Social Care Trust, who is the deputy chair, and Mr Bill Forbes, the chief officer of CAWT.

This opening statement describes CAWT’s cross-Border working arrangements and outlines health and social care services currently supported by the partnership through various initiatives.

Founded in 1992 with the signing of the Ballyconnell agreement, the CAWT partnership is a unique structure providing an overarching framework for the planning, management and implementation of cross-Border health and social care. The core purpose of CAWT is to support its partner organisations in the Republic of Ireland and Northern Ireland in their collective work to improve the health and well-being of the people living in the Border region and to enable better access to health and social care services. CAWT does not in itself deliver services.

In Northern Ireland, the CAWT partners are the Health and Social Care Board, the Public Health Agency, the Southern Health and Social Care Trust and the Western Health and Social Care Trust. In the Republic of Ireland, the partnership comprises the Border counties of the Health Service Executive.

North-South co-operation underpins all CAWT’s cross-Border health and social care activity, which is driven by the needs of the region and the health priorities of all the key partners, focusing on supporting the needs of people along the Border corridor. A key responsibility of the CAWT partnership is the provision of co-ordinated and strategic oversight ensuring work undertaken complements national Government and Department of Health priorities in both jurisdictions.

Significant EU grant funding totalling €31.1 million, under the current INTERREG VA programme, has enabled the CAWT partnership to demonstrate how investment in cross-Border health and social care services improves access to health services and enhances care, particularly for people living in rural or remote areas. The INTERREG programme is the fourth EU funding stream through which the CAWT partnership has successfully implemented projects to support the needs of local people on the Border corridor.

Preparatory work is under way in reaching a state of preparedness for the partnership’s application to the PEACE PLUS EU cross-border programme, the special EU programme body’s new funding measure which builds upon previous PEACE and INTERREG programmes. As members may be aware, the new PEACE PLUS programme is set to launch later this year. Under the six themes of the programme there will be up to 22 separate investment areas. The programme has not yet been approved by the European Commission, although it has been approved by the Northern Ireland Executive, the Government of Ireland and the North-South Ministerial Council.

Equally important, of course, is the commitment of the health services, North and South, to work in a collaborative way where a joined-up approach to service developments can bring mutual advantages.

Five projects, funded under the current EU INTERREG programme, are under way - four led by CAWT and one led by NHS national services in Scotland. In the interests of time, I will not read them out, but they include acute hospitals; community health; the innovation recovery project around mental health; multiple adverse childhood experiences, what is called the MACE project for children; and mPower, which supports older people.

In addition, the CAWT partnership facilitates other non-EU-funded cross-Border North-South activity, including all-island emergency planning, including joint academic learning and the delivery of humanitarian disaster assistance training. In November 2021, a very successful cross-Border humanitarian disaster planning course, hosted by the United Nations Training School in the Curragh, shared experiences and learning from a range of military and health contributors on the Irish-British response to Covid-19.

CAWT plays a key role in the facilitation of North-South health and social care co-operation supporting initiatives commissioned directly by the Departments of Health. This work has resulted in major developments such as the primary percutaneous coronary intervention, PCI, at Altnagelvin Hospital in Derry, which has been treating patients from County Donegal since May 2016 and the north-west cancer centre at Altnagelvin, which provides radiotherapy services to patients from Donegal, also since 2016.

Throughout 2019, 2020 and 2021 both the Northern Ireland and Republic of Ireland Departments of Health engaged in the preparations for the UK’s withdrawal from the EU. In 2018, both governments agreed to underwrite the INTERREG VA EU funding allocations, which was welcomed by all CAWT partners. As a result of these assurances, despite the uncertainty surrounding EU exit arrangements, the CAWT partnership remains cautiously optimistic that post-Brexit arrangements will not obstruct existing cross-Border and all-island health and social care service provision or limit future service developments.

Historically, when obstacles to the development of cross-Border services were identified, many practical solutions have been developed by the CAWT partnership. For example, a cross-Border indemnity agreement allows health and social care employees to work in both jurisdictions within a range of contexts described within the agreement. Regarding emergency planning, professional and regulatory bodies agreed for their registrants and members to provide services in the opposite jurisdiction in the event of a major incident while remaining accountable to their bodies.

To maintain and further develop the solid working relationships that are now an everyday experience in the health services, North and South, CAWT remains committed to its focus on key strategic goals including: achieving solutions to barriers to the cross-Border mobility of patients and professionals; actively pursuing collaborative strategic alliances; actively engaging with policymakers and other key stakeholders on the development and direction of cross-Border health and social care; and embedding cross-Border planning and implementation in core activities where mutual benefit can be gained through service efficiency and effectiveness.

Despite the uncertainty presented in recent years we continue to work collaboratively to improve the lives of people living in the Border areas.

Chairman

I thank Mr. McCallion for outlining CAWT's very comprehensive initiatives. As agreed, the sequence of speakers will be Sinn Féin, Fianna Fáil, Fine Gael, SDLP, Alliance, Green Party, Sinn Féin, Labour, Independents and Aontú, with each speaker having 12 minutes.

Ms Michelle Gildernew

I will speak first to be followed by Deputy Conway-Walsh. The witnesses are very welcome. Mr. Guckian and I worked together in the Western Health and Social Care Trust and so I have a wee grá for him, but I ask him not to take that personally.

I am a big fan of CAWT. As the MP for Fermanagh and South Tyrone, I have engaged with the partnership since its establishment. One of the most insightful meetings I ever attended was when CAWT made a presentation to the then Ministers for Health at a North-South Ministerial Council meeting. I believe I told Mr Guckian what was said at that meeting; I will not repeat it now. I had the privilege of being the accompanying Minister along with Mr. McGimpsey when Tom Daly gave a presentation to us many years ago.

CAWT has been transformative because it has allowed us to provide essential services to rural people generally and those living in Border communities much more locally. If I get a question about a service relating to a gum clinic or whatever, CAWT is the go-to body to find out where that service is being offered and how my constituents can access it. The work it has done, straddling the Border working with the Departments of Health, North and South, is likely to be pivotal if we are developing an all-Ireland national health service, for example, which I hope will happen in the future.

Understandably, CAWT has placed considerable emphasis on preventive measures and risk factors associated with chronic illness such as heart disease, cancer, respiratory illness and mental health conditions in the Border areas. Has it made recommendations to the relevant Ministers and Departments on how health provisions can be improved?

Has there been progress made on these issues? I am particularly asking about the Western Health and Social Care Trust and Dr. Susan Connolly and the work she has done. I am aware there has been a bit of difficulty with getting that funded so it would be great if we could be given an update on that.

Mr. McCallion said he was cautiously optimistic about EU funding. I think we are all afraid Brexit would have a very dramatic impact on CAWT, how it delivers services and how it accessed EU funding as a way of doing that. Are there plans for further EU grant funding for projects the coming period in 2022? Where are we on that? I will leave it there and hand over to my colleague, Deputy Conway-Walsh.

Deputy Rose Conway-Walsh

I thank the CAWT representatives for the presentation and for all the good work they are doing. My first question is, when will the programme be approved by the EU Commissioner? When are they expecting that and how time-sensitive is it? Are there risks if it is not approved sooner rather than later? How successful was the recent health and well-being programme, which set out to train the 40 local community health facilitators to deliver the healthy lifestyle programmes to the residents of their communities? What areas were those delivered in and how does CAWT evaluate them?

One of the biggest challenges we have in the west of Ireland and in rural Ireland is the shortage of GPs. How is that impacting on what CAWT is trying to do? What do the representatives see as the solutions to those? I am not sure if the organisation is involved in the associate physician developments. Maybe the representatives could speak to that as well. I have other questions but I want to give them time to answer.

Chairman

There are eight minutes left in the slot.

Mr. Damien McCallion

I might take a couple of points broadly and my colleagues Mr. Forbes and Mr. Guckian might come in as well.

On the learning and going back to the Departments and the Ministers, we are comprised of the partners that deliver care on the front line but we work closely with the Departments to try to influence policy. On the INTERREG EU projects, there must be an element of innovation. It cannot just be doing what you are doing, so we are always trying new things. I will give one example to illustrate. Community paramedics are a new development Mr. Forbes spearheaded in a former role. The ambulance services could go out on call from GPs or from 999 and were not obliged to necessarily take patients to hospital. They were trained to a higher level. That was piloted in Donegal, Monaghan and Tyrone. We also worked with Scotland as the training and education was done there. It was a very innovative type of project. We take that sort of learning back into our respective service planning or annual processes with the Departments if we feel it has been successful. Mr. Forbes might talk about the evaluations and some of that in a moment.

On the timelines from the PEACE PLUS programme, we are fairly confident. We do not have a specific timeline on it but in talking with the CEO of the special EU programmes body, SEUPB, she is confident we will be moving to calls at some stage later this year. We have been doing a huge amount of work to try to build up what we see as our priorities around the Border region with colleagues in both Northern Ireland and the Republic to look at how those joint projects can work. They might be initiatives where patients move, clinicians move or just where there is learning between the two jurisdictions from doing something together and learning from each other even though both may have different regulatory positions and so on. We are optimistic. At the moment we do not see that being an issue for us. We do not have an exact date but from talking to the SEUPB it is confident we will probably be going for calls later this year. For the last 12 months we have, believe it or not, been working to build up those proposals because it takes a huge amount of time to get all the partners to the same place, ensure the priorities are the same, ensure there is good clinical buy-in and good support around it. There is, therefore, a huge amount of work Mr. Forbes and the team facilitate between the partners. I worked on it in the HSE, so we know those things take time. We have been working actively on those for the last 12 months.

I ask Mr. Guckian to talk about the Western Health and Social Care Trust. He probably has a closer handle on that than do I. We will come back to some of the other questions on GPs and health and well-being. I ask Bill to come back on some of that.

Mr. Neil Guckian

Ms Gildernew will be well aware the Our Hearts Our Minds programme is not part of the CAWT programme. It is a separate transformational project that is being delivered within the Western Health and Social Care Trust. Our priority on that is to try to convince our funders in Northern Ireland of the merits of that. I can confirm the Western Health and Social Care Trust has shared both the benefits and indeed the service impact and post-project evaluation of all trusts in Northern Ireland and the Commissioner and the Department of Health. It is important we do that before we start trying to spread it across the Border. As members have already been told, it is all about innovation and we must prove the innovation can be spread before we can look to bring it across borders. That is the Our Hearts Our Minds programme. As we are still looking for the funding for next year, any influence Ms Gildernew can have we will obviously appreciate.

On physician associates, we have piloted that in the Western Health and Social Care Trust. Indeed, my previous employer, the South Eastern Health and Social Care Trust has been piloting physician associates. It is too early to say whether it is the overall solution to shortages of GPs, or indeed consultants, middle grades and juniors in hospitals in Northern Ireland, or indeed the South. The recruitment of qualified medical staff, be they GPs or consultants, is very challenging. On the physician associates, the jury is still out as far as the impact it will have is concerned. We are committed to the programme and will see at the end of that whether it will be the answer. I see it as part of the future if we can define the role very well and define what element of the medical service they should deliver to reduce the workload of our consultant workforce. On the shortage of GPs, Ms Gildernew and I have had many conversations about it, especially the shortage in rural areas. It is problem common to Northern Ireland and the Republic of Ireland and clearly it is something CAWT can link into. We struggle for the solutions. The innovative side to it is really the challenge. It is about trying to find the answers to that. Where we have a common problem, CAWT can be really influential and helpful to us in solving common problems.

Deputy Rose Conway-Walsh

That is great. How important does CAWT think cross-Border enrolment is for students? We are doing a project on that at the moment and examining training and education opportunities across the island so we have a shared approach to that.

Mr. Neil Guckian

I am flying the flag for the Magee medical school. Everywhere I go, I am very proud of the innovation and the development within Magee and I encourage all communities to sign up to it. I see that as helping us create a corridor in terms of the future for the medical workforce.

Mr. Damien McCallion

I will add to that by mentioning the work on the indemnity, for example. Those things are very important to enable people to move, whether in a student capacity or otherwise, where people can work across, especially in areas of specialisation. It is important for patients that you look at a wider population. Mr. Forbes can speak to some of the initiatives that are not CAWT initiatives but that CAWT would have facilitated, such as the percutaneous coronary intervention, PCI, where people who have cardiac arrest and so on in Donegal can now go in to Altnagelvin Area Hospital and get immediate treatment that would not have been available heretofore. The lives of several hundred people have been saved as a result of that initiative. Those things take a long time to give effect to the regulatory, legal operational and other considerations.

I ask Mr. Forbes to respond on the health and well-being development and the evaluation.

Mr. Bill Forbes

On the health and well-being, that co-sited project has successfully closed. It reached its full target of over 10,000 beneficiaries. The Deputy's question was around the community facilitators. The target was 40 and we trained 60. We exceeded that number as well. That was with the support, obviously, of the SEUPB through some very difficult times through Covid. We have had to go for a number of requests for change to our delivery model, our timelines and the targeted community we were trying to reach. Many of these people were not engaging and we had to look at new platforms of e-health and telemedicine to bring those targets and those beneficiaries up to what we had promised.

On the PEACE PLUS piece, we are working very hard with all the strategy groups North and South and we give assurances on that. We believe that funding will be called in 2022 and we are working tirelessly to bring that to a phase of complete implementation. We do not see that being referred any later than the end of 2022.

Deputy Rose Conway-Walsh

Okay.

Mr. Damien McCallion

On the evaluation, under the EU rules for the programmes very stringent evaluations are needed. Each of the projects will have a formal evaluation of what worked and what did not. One of the things we try to learn from is with innovation everything cannot work. Some things will work and some will not. It is important then to understand what you might do differently. To illustrate, because these are innovative projects and only running in small pockets - this links back to the earlier question - what we do is each jurisdiction, if you like, has the responsibility to see what it wants to bring forward. The programmes have a certain shelf-life. They are only funded for a certain number of years but in the last round of funding in the previous programme, over 80% of the projects were what we call mainstreamed. In other words, say there is a disability project in Donegal, that was then brought forward on a wider scale within a local area and then potentially, if it is very successful, nationally.

The Deputy may have seen I mentioned one of the projects on mental health, recovery college, where one uses people who have had lived experience of mental health to work with other people. That is innovation which is used in other parts of the country. I have seen a very good example of it in Kilkenny from another experience in another role. That has worked very well for us and is still going. The project is still running in both jurisdictions.

There is a very stringent evaluation process under the EU programmes and one of the key things the CAWT office, Mr. Forbes and the team, support us in as the partners to try to facilitate and broker that in terms of project management and things people may not have the capacity to do otherwise in the services, because as we know from the health services in both jurisdictions, the one common trend is that they are both under enormous pressure. Demand is very high. Having that support of people who can help those projects to go forward and still meet our obligations to the EU is crucial.

Deputy Brendan Smith

I welcome our witnesses and compliment CAWT on its work over the years. As Ms Gildernew said, we had engagement with Tom Daly many times. It was always very useful. I do not think I will engage as positively now with him when he is trying to take the Ulster final in Clones, to bring it to a revamped Casement Park. We would have a slight difference of opinion on those issues, but I compliment Mr. Daly and all who have pushed out the CAWT programme so successfully.

CAWT was very fortunate in its place of birth in Ballyconnell. It had a very good start to life in the first place. I just noticed it has quite a disparate number of groups to work with in Northern Ireland. We often think our health service is not consolidated enough but when I see the number of different partners and providers CAWT has to engage with in Northern Ireland, I am sure it is not that easy.

The Minister for Public Expenditure and Reform has indicated to us that he expects to sign off on the PEACE PLUS programme in the not-too-distant future. In our parliamentary party, as Senator Blaney could attest to, we have been urging him to move it along as quickly as possible. No obstacles are foreseen at this stage to signing off on it. We would be very glad to do whatever we can do to support the programmes CAWT put in for consideration because all of us have experience of the good use to which it has put relatively small money in the past. It influences all of our opinions.

Deputy Conway-Walsh touched on some skills and medical shortages. We also know of the shortages of other clinicians, therapists and nurses. Does CAWT have any particular project in which it would train people specifically for the Border counties in collaboration with the institutes of technologies and the general hospitals? I know that in my local hospital, Cavan general hospital, we have nurses who are doing their nursing degree in Dundalk Institute of Technology. I assume it is the same in Sligo.

Could there be a specific project to try to train more people? I hope more people would take up jobs in the area where they are trained. It is not easy to attract young clinicians to more remote areas. I will go back to the GPs as well. It is generally accepted that the age profile of many of our GPs in rural Ireland is high, unfortunately, and it will not be easy to get replacements. From a number of incidences I have dealt with in my constituency, I know the HSE has struggled to try to get people even to apply for some vacancies at times.

We have two different health systems, North and South. Is there any way consideration could be given to some cross-Border GP practices? In remote parts of the area that I represent, going in to Mr. McCallion's area in north Leitrim, Cavan and Fermanagh, there are small GP practices on both sides of the Border. When the practitioner retires, it is extremely difficult to get a new incumbent. It might be worth giving some thought to practices being merged or amalgamated to some extent. I appreciate the structural difficulties there are with two different systems, but we have to think outside the box to ensure we have reasonable access for people to GP care in rural areas. It is extremely important.

We live in an era now, with a particular emphasis by An Taoiseach and the Government on the shared island concept, when we have to see more working on a cross-Border basis. We have to see more collaboration. Over the years, in the past, the hospital in Omagh used to provide EMT services to Cavan and Monaghan. A limited service is now provided by Coleraine. I do not know if it is in CAWT's remit but we have to have more provision of acute services on the basis of collaboration.

When there was a big challenge in regard to replacing the Erne hospital in Enniskillen and Omagh, I remember at the time, the thinking was that the very substantial south west hospital would collaborate with Sligo and Cavan general hospital. To my knowledge, what we want has never been achieved and we have to have a focus on delivering services, such as specialties, on a cross-Border basis. We have to try to move out whatever blockages there are. If I have a constituent in Cavan or Monaghan, they want to get the service as quickly as possible, as I am sure our neighbours north of the Border do.

Will the witnesses give some update on whether any progress is being made in that respect? I know they deliver services, but I am sure they have an input in policy up the line at Department and Government level. Is any thinking going in intensifying co-operation and the delivery of services at general hospitals on either side of the Border, to service the needs of the people on a cross-Border basis, in particular specialties?

I very much welcome the work CAWT does. As a public representative who has been familiar with that agreement from its inception, I would be very glad to support its work and I sincerely hope the programme it puts forward to the special European Union programmes body that it meets with approval.

Chairman

We will add at least two minutes.

Senator Niall Blaney

I compliment Deputy Smith and go back to the outset and the mention of Tom Conaghan, a great Donegal man and politician in his own right. Services in Donegal have been very well looked after in the past and I certainly look forward to that continuing. The presentation mentioned the services that exist between Donegal and Altnagelvin. I am aware of patients whose lives were saved as a result of the service provided at that location. With regard to the radiotherapy services, however, there was political intervention here and there along the way that gave an aura that the priority of Altnagelvin was to deal with patients on a northern basis. There is certainly a feeling that patients south of the Border are playing second fiddle.

Moreover, I encourage what Deputy Smith has said on the shared-island funding. I think the Taoiseach is on record as saying quite an amount of funding is there now and there are several issues all along the Border where deficits exist. Has CAWT examined possibilities or proposals for projects to tackle new issues that exist on the ground, such as accident and emergency services?

In this country, we are inclined to take an approach of centres of excellence. It is my opinion that all centres of excellence do not have to be in one location. It is about the disciplinary team. There is nothing stopping us having centres of excellence in Altnagelvin, Donegal, Cavan, Monaghan, Enniskillen, Daisy Hill, which I am told is also struggling, Dundalk and other locations all along the Border. There are massive possibilities.

(Interruptions).

Chairman

I do not know who that is.

Mr. Damien McCallion

I will open up on one or two of the points and then ask my colleagues, such as Mr. Guckian, to come in on some of the more specific things on Altnagelvin. With regard to the challenges for rural areas, it is interesting in that the whole INTERREG programme is framed on the basis that regions around Europe generally have more deprivation and challenges in terms of employment access to many services, including healthcare.

As the Deputy said, that brings its own challenges in terms of attracting people to certain roles. We had a previous CAWT project in the last round of funding in regard to how we could encourage more people into those rural areas, which is a challenge from Donegal right along the Border corridor. That tried to explore some of the issues and came up with ideas about how we would address it. In this round, it is more specific to projects and we have tried to recruit people. For example, mental health is very challenged in regard to getting access to mental health care professionals. The recovery concept is using people with experience of mental health to support a process but, obviously, under a clinical governance model within mental health services.

One of the things we are looking at for the next round of funding - one of the thematic areas - is to have an initiative. There is a stream within the new programme around professional development and mobility, and also the challenges in some areas. The key themes there will be the issues we all face anyway within our own jurisdictions, given there are not enough people globally to go around for certain disciplines, training numbers and so on. Some of those are issues within the jurisdictions. What we are trying to do is, first, ensure it is easy for people to operate on both sides of the Border, which facilitates mobility, but we are also trying to look at areas where we could identify certain priorities for working. That is one of the areas where we would hope to develop a proposal for PEACE PLUS.

In terms of the specialties on the GP side, specialist training and so on, there is collaboration. Mr. Guckian talked about the Magee medical school but there are big challenges around general practice. We had a couple of small initiatives where pharmacies and GPs did work on out-of-hours services across the Border, whereby some pharmacies could prescribe from Northern Ireland into the South, but they are very self-contained. The point the Deputy makes is a good one which we will take away.

When we look at GP challenges in both areas of the Border counties, we need to ask if there are things that could be done. However, some of those do stray into policy areas. We are very clear that our role is getting healthcare partners to work on the ground to identify areas, and then work with policymakers or with the legal bodies on indemnity and so on in order to resolve those issues. We are not the policymakers but we link in very closely because we are getting feedback from people out there in the real world and in the environment.

I will ask Mr. Guckian to talk around some of the points on the Western Trust.

Mr. Neil Guckian

With regard to radiotherapy, I assure the committee that all patients from the South of Ireland will get the utmost clinical support. There is absolutely no two-tier service. As chief executive of the trust, I can categorically state that. All feedback we have received confirms that in terms of clinical outcomes and clinical support. We have overcome a lot of the early teething problems about information flowing across the Border and all the various challenges that presents, but I can assure the committee that all evaluations have come out showing identical outcomes for both categories of patients.

In regard to the south-west acute hospital, I have to confirm that we do not have the traction in terms of the cross-Border linkages between south-west acute hospital and Sligo hospital. That is an area of great regret for me as chief executive of the Western Trust. The challenge for all chief executives of smaller hospitals is to sustain those hospitals into the longer term, in particular their acute status. I would be very keen to engage with Sligo hospital and others to try to see where we can help each other in terms of the long-term sustaining of services. It is a great regret that it has not taken off over the last decade.

In terms of new centres of excellence, I can assure the committee that the cancer centre in Altnagelvin is a centre of excellence, and one that we should all be extremely proud of for the island of Ireland. There are other centres of excellence throughout the Western Trust and, indeed, for the Saolta Group in Sligo, Letterkenny and Galway. We should be extremely proud of our health and social care services in the area.

CAWT has played its part. We would not have a cancer centre today if it was not for CAWT, and the population of the north west of Ireland has really benefited from that development. As the people responsible for delivering the service, we are aware that we would not have that without the Government, the GPs and the medical people of Donegal, but also through CAWT. I think we have a lot to be proud of, although there are a lot of challenges ahead.

Mr. Damien McCallion

I am conscious I was asked to make a point on the shared island concept. We would see potential. We have tried to focus on the priorities from a health and social care perspective and then almost look at where the funding streams can support us. We need to be clear that people are committed to the projects because each of these takes substantial effort when everyone is already under pressure. Innovation is great but when a system is under pressure, like the health service has been for the last few years, it can be hard to engender that enthusiasm in people who have been through very tough times for the last two years. CAWT plays a role in trying to take some of the project burden away. We can facilitate that, appoint project managers and try to pull people out to support that, so we are certainly looking at that. We have a set of priorities around mental health, disability services and what we call integrated care, looking at areas like obesity, renal services and medicines management. We will then look at putting the right submissions in, which we know we can deliver through all of the partners, both through the EU’s PEACE PLUS and also in regard to potential opportunities on the shared island.

Colleagues in the Department are working with both Departments in Northern Ireland on areas like cancer research under that collaboration, and there is also potential around the specialties and on more policy-related areas like specialised services and how we could collaborate. CAWT would facilitate that. Although we are not a statutory body, there is a huge amount of experience from the chief executives. As Mr. Guckian said, the chief executives of the Saolta Group and the RCSI Group, for example, are active participants. While CAWT might not be directly responsible for that, it allows those relationships to form that ultimately make things work.

The Deputy mentioned my predecessor, Tom Daly, and I acknowledge his work over the years. I will pass on the Deputy’s kind words to him and the criticism on moving the Ulster final out of Clones as well. A lot of that work was made possible through people having relationships and trying to do that. It is helpful that both at the policy level and from the ground up, we can bring those two parts together to make things happen. That has been the experience over the years. In some ways, we have often been asked whether we would be better as a statutory body. There is probably a strong view that we are not, because it allows that collaboration, free-flowing discussion and dialogue to try to create these things, which are the right things to do for people who live in Border areas.

Senator Emer Currie

The more the witnesses talk, the more I learn about what it is they are doing. They seem to be very solutions-orientated in terms of bringing projects into the community.

When I read the briefing, my question was around resources. I am also interested in the qualifications. Are there any barriers between the qualifications that people have? One of the issues that comes up again and again is the number of psychologists and therapists. We have a limited number of psychologists getting their doctorates every year. In fact, part of the problem here is that the clinical psychologists are paid for their placements for their three years and they get funding towards their fees, but that does not happen when it comes to educational psychologists or counselling psychologists. I wonder if that is the case in the North as well, given Queen's University does trainee doctorates as well. I ask for the witnesses’ view on that and whether qualifications are a barrier.

The witnesses said they are not policymakers. I want to ask them about the minimum unit pricing that was brought in for alcohol. Obviously, that is a policy that aims to reduce hospitalisations and deaths, but price differentiation is an issue, North and South, or a potential issue - I have not seen the data yet but it has been flagged. We were supposed to move together. We had hoped that both jurisdictions would move together on that but it seems legislation will not be forthcoming in the North until 2023, although there might be a public consultation on it this year. Is that on the radar of CAWT? Is that the kind of thing that gets in the way? Does CAWT have influence to advocate for that to be introduced?

In terms of getting this straight in my head, I want to ask about the current instability in regard to Stormont. How does that affect CAWT? How does that slot in with the North-South Ministerial Council? Is this something that has been set up separately in terms of co-operation or does CAWT link in through the North-South Ministerial Council?

Chairman

I am very interested in the last paragraph in regard to the community health synchronisation project. One of the key issues nowadays, particularly in our media, is isolation of older people and attacks at home, with a 73-year-old man having been criminally assaulted.

I appreciate what has been said about local support, bespoke solutions, isolation packs, friendly calls and all of that. Has that issue been addressed? What is the best initiative the witnesses are aware of that might be introduced in order to give older people, individuals and couples, living alone a sense of security, awareness and support? Are there systems such as alarms that they can wear to alert people if they fall? Is there any integration in that regard because it is a growing issue?

Mr. Damien McCallion

Mr. Forbes will respond first and then I will pick up on some of the points on education.

Mr. Bill Forbes

The community health synchronisation, CoH-Sync, project is currently a very successful one, with more than 10,000 direct beneficiaries. The project covers a number of key areas for the elderly: loneliness, management of healthcare, healthier lifestyles, diabetes, alcohol and drug management. Through our integrated care programme, frailty is one of the issues we will address in the current PEACE PLUS programme. Frailty covers a number of areas: everything from falling, telemedicine, loneliness, and the impact of isolation due to Covid-19. We all know the data on that. Isolation is not good for anyone's health, and it has a detrimental impact on it. Frailty and looking after the older population, who we see as very vulnerable but very valuable, is one of the key aspects under the six themes of the integrated care programme for PEACE PLUS. The CoH-Sync project is currently undergoing independent evaluation. As Mr. McCallion stated, more than 85% of our programmes have been mainstreamed. The next mainstreaming meeting will be in June 2022. We will see which programmes to choose, and we will try to influence policymakers to mainstream them, along with the other ones that we have. Our objective is to mainstream all our projects.

Chairman

Perhaps Mr. Forbes could contact us after the meeting so that we could campaign for it. There is a greater interest in this and there may be more effective political involvement in it after this negative period.

Mr. Damien McCallion

We will send the annual report and some of the more recent progress reports.

Chairman

That is very important. Could the witnesses respond to Senator Currie's questions?

Mr. Damien McCallion

In terms of the immediate impact, I might ask Mr. Guckian to comment as well on the educational side. CAWT is not a statutory body so we do link into the North-South Ministerial Council, but we exist on the basis of collaboration, so it is about the partnerships between people and the EU programmes give us a certain structure. In one way, we can operate to an extent, although I will not say independently, on some of the wider issues. We try to focus on what we need to do on the ground and we work through the projects and programmes with the SEUPB, which is separate to the North-South Ministerial Council, albeit the policy direction that is set out for PEACE PLUS or INTERREG is determined in conjunction with the two Departments and other stakeholders, voluntary groups and community groups.

Of the projects that we have, a significant proportion of them involve community groups, so although the projects are being run through the statutory providers, the HSE or the trusts, we will then subcontract out a lot of the work, for example, as Mr. Forbes said, some of the community health and well-being projects or mental health projects involve working with community groups and sometimes that will take away the burden of all the overheads that come with some of the complexity around the EU programmes and projects. While the more conducive the environment is, the easier it is to operate in, notwithstanding that, even where there are challenges in the wider political environment, our focus is just on the services on the ground and those collaborations between the various partners and delivering the projects. In some ways, we try to get on with that. We also look at where there are opportunities. I referred earlier to measures such as on indemnity, which facilitate cross-Border working.

I cannot pretend to be an expert on the educational and psychology side. Again, it would be outside our remit, but where these issues can surface for is if we had a project, for example, that impacted on that, we might take on the challenge of trying to work with the various Departments or groups to look at resolving issues to make it work, like we did on indemnity, for example, to ensure medical practitioners and others could work in both jurisdictions, and similarly a licence for ambulance staff, as Mr. Forbes will be familiar with. To be honest, it is not a particular one that we have come across. Perhaps Mr. Guckian wants to comment on that as well or on the wider issue of education.

Mr. Neil Guckian

The only comment I will make about education is that the issues relate to registration. Before recent changes, registration would have been much more automatic in Northern Ireland and in the South. Now we are finding that people must have much more dual registration. That has been embraced. We have gone through a process in my organisation to make sure that can happen so that no patient or client is left without service as a result of a process. It has been tricky enough, but we are getting through that and we are now in a better place.

In response to the question on instability and how if affects us, since 1992 CAWT has had many different hurdles in terms of instability, and we have overcome them. However, I would highlight that CAWT has focused in on the operational side of health and social care so, by and large, it functions, irrespective of the instability going on around it.

Regarding minimum unit pricing policy, CAWT would not have a role in that. As chief executive of the Western Health and Social Care Trust, I have my own view but it would not be a function of CAWT to comment or to have an input into such a policy.

Chairman

We will move on then. The other question I have relates to waiting lists for podiatry and other such services. In my community healthcare organisation area more than 500 people over the age of 65 have been waiting more than a year for services, which has an impact on the health services. Are there initiatives relating to the sharing of services or facilities?

Mr. Damien McCallion

In the past, we have had initiatives focused on that, for example, ophthalmology and other services. What is important to remember in terms of EU funding is that it is largely a case of trying to focus on new and innovative ways of doing things rather than being able to solve an existing problem. Having said that, it does also facilitate some of those arrangements, such as ENT, between the Southern Health and Social Care Trust and the north-eastern area. Mr. Forbes might want to talk to those. There is ongoing collaboration around ENT in those areas, so it is a legacy of a project that we would have done and then that is sustained in some way. The projects are very much focused on innovation and trying out new things and if they work to mainstream them. CAWT would not be responsible directly for those, but as a result of the work within CAWT sometimes the partners might collaborate and identify if they can get extra capacity or resources and work together to avail of that. Mr. Forbes or Mr. Guckian might want to say more about it.

Mr. Neil Guckian

I can confirm that the Western Health and Social Care Trust and Letterkenny hospital have been working very closely on waiting lists for urology, vascular and other areas. Appointments have been made as a result of EU funding for clinicians to tackle common waiting lists using innovative approaches to the interventions. It is about linking in the requirements of the EU with the requirements of the waiting lists.

Chairman

There is a problem in the South with GMS dental services where people cannot get attention. Thousands of people in my constituency had, let us say, 40 dentists they could go to and now it is only 20. The service is not available, and it is a significant factor in health because poor dental hygiene leads to other problems and can lead to serious issues. Is there co-operation in that regard or is there a demand for such services?

Mr. Bill Forbes

There is no identification of that project as yet. To reinforce what Mr. Guckian says, there is cross-Border agreement on clinicians and patients between the Republic of Ireland and Northern Ireland for services such as vascular, geriatrics, dermatology and urology and the project is very successful. It operates under INTERREG VA, which has exceeded its beneficiaries by more than 10%. That is working very well. Covid did have an impact on all services, but we came up with innovative ways of bringing those services forward. We have started a new programme.

Chairman

I am not sure about Northern Ireland, but I presume it is the same as the UK where, as in the South, there is a significant backlog in health services, in particular outpatient services and cancer diagnosis. The work of CAWT therefore increases in importance. Increasing co-operation is critical to everybody's healthcare, North and South. I very much like what the witnesses are talking about. I would appreciate if they could send us more data and the annual report. It is very important for us, in that although we live in different counties and we have different problems, in one respect they are the same in the sense that we do not have enough services.

Mr. Damien McCallion

One of the challenges for CAWT is trying to facilitate those partnerships but, as you say, Chairman, coming out of Covid we have waiting lists in both jurisdictions.

We are examining whether there is something innovative we can do that will help both jurisdictions in some scenarios. I am familiar with the scenario in the South but in the Northern Ireland context, it may or may not apply. We have to focus our energy on particular priority areas. When we initially come together, North and South, there could be a couple of hundred ideas in the room and we have to try to filter them down to core projects that will deliver value and meet the EU's objectives on being innovative. The areas of medicine management, frailty services and obesity have been identified for this round. We also have to make sure there is alignment, by which I mean good commitment in both jurisdictions and among the various partners to a given project. It is not that all of these matters are not priorities but given that there are so many demands on the health service, we have to make sure we can deliver those projects. Last time, 80% of the projects ended up being mainstreamed when the EU funding ceased and we want to make sure we are hitting that sort of range again.

Chairman

It is important that there is continuity post the EU support.

Mr. Damien McCallion

Yes. Having been on the service side, I can still recall meeting families in disability services where we had put in peer workers for young people with autism. The funding had run out and we were in the recession at the time. Meeting those families and seeing that those services could potentially cease was a stark reminder to us all. At the time, we managed to resolve the issue but it emphasised the importance of having some sense, when taking on a project, of how we might be able to mainstream it so people are not left behind.

Ms Claire Hanna

It has been really interesting to hear about the work that CAWT is doing, which is at the core of what we should all be doing because cross-Border co-operation and all-island co-operation are about materially improving people's lives. We have probably not done as much of that as we could have over the last couple of years.

A feature of the way this committee works and the rotation is that all of the good questions have often been asked at this point. In the preceding contributions colleagues have asked lots of very good questions. Of course, I do not have a constituency overlap so I do not come across the work of CAWT on a day-to-day basis but I have a couple of questions which follow on from Senator Currie's questions about qualifications. Mention was made of the need to embrace the dual registration issue. Generally, how are things for healthcare workers in terms of being able to deliver services and move around seamlessly? The witnesses said they have embraced dual registration but do they have the opportunity to deal with issues like that? If they hit an administrative barrier, perhaps flowing from Brexit, are there ways to have that addressed?

Covid obviously laid bare the challenges of working between two jurisdictions but I imagine it has probably also accelerated the integration of some services and sped up some of the changes that were probably already happening in the delivery of health services generally. What would be CAWT's top-line learnings out of Covid? How has it changed what CAWT does?

Mr. Damien McCallion

On the qualifications question, where CAWT has tried to support services on both sides of the Border, it has been in particular targeted services where we have projects running. It is not on a wider policy basis in terms of registration and how we overcome some of those challenges to allow people to work in both jurisdictions, where that is of value. Not all of the projects require that. Sometimes it is a scenario where people are moving but other times it is in a learning or a joint project, like the community paramedicine project, where we gain the advantage. I will ask Mr. Forbes to comment on some work that was done in emergency ambulance services, where people can work in the two jurisdictions. I will also ask Mr. Guckian to comment on one or two of the wider points.

Covid has affected us all and both health systems have been severely impacted by it. It has affected some of our projects but we have managed to work through the obstacles and keep things going. An awful lot of healthcare staff, even those who were working on our projects, had to be moved and had to prioritise Covid care. It has been a difficult couple of years and yet the projects have managed to keep moving, albeit at slightly reduced levels than we would have originally intended. I will hand over to Mr. Forbes who will talk about the ambulance work and then to Mr. Guckian for a more general comment.

Mr. Bill Forbes

From an ambulance service perspective, involving the National Ambulance Service in the Republic of Ireland and the Northern Ireland Ambulance Service, co-operation between both services is second to none. There was an issue a number of years ago around dual benefits for both organisations and we progressed two memorandums of understanding. One was on the response to any major incident and the other was on a request for mutual aid. They have been invoked on a number of occasions, including in quarter 4 of 2020 and quarter 1 of 2021, when the Northern Ireland Ambulance Service experienced extreme pressures and the National Ambulance Service in the Republic of Ireland was asked to provide resources into Newry, Enniskillen and Derry. That was done over a number of days and weeks and that memorandum of understanding is still in situ. To reinforce it even more, we do joint training, joint exercises and joint academic learning to ensure it works. The clinical directors from both organisations and both Departments have agreed that this mutual working across the Border is indemnified for the benefit of patients.

The other piece is that we do not work in silos. We also work with the Western Health and Social Care Trust and we have trauma bypass protocols which allow us to take very critically ill patients, if they are geographically closer to Altnagelvin, straight there without any clinical issues. The other big programme is the north-west percutaneous coronary intervention, PCI, programme where patients are being transported and treated across both jurisdictions, travelling from Donegal straight into the primary PCI centre in Derry without any sort of indemnity issues, stopping or having to switch vehicles, staff or patients. That whole piece on the front line works very well.

Mr. Neil Guckian

In relation to issues arising from Brexit and their impact on the workforce, we are in the middle of a process of identifying the costs. I am still optimistic that those costs will be funded from the Department of Health as we identify them. Obviously, I will continue to labour that point.

Ms Hanna asked about the learning from Covid and that is a really interesting question. The first learning is around the use of technology and in terms of virtual clinics and virtual working, we have certainly embraced that much more. It has its place and while there are times when it is not appropriate, by and large we need to ask, particularly in outpatient environments, if the work can be done remotely. The second point I would make, in the context of responsibility for services in my area, is that the impact of social deprivation on health outcomes has been much more stark in the context of the pandemic. This includes something as basic as access to vaccinations and the difficulties for people if they have to get four buses to get to a mass vaccination centre. I am extremely proud that the Western Health and Social Care Trust had three mass vaccination centres within its area but even with that, when we analysed the low uptake we found that it was mainly in areas of high social deprivation, and we had to organise more mobile clinics in those areas to make sure we targeted everyone in society. There is also a linkage from social deprivation to chronic disease prevalence.

The third point I would make is on the need for collaboration and there was no better example of that than our approach to Covid worldwide. The same approaches were taken worldwide and certainly within the jurisdiction of Ireland. It has been very interesting to see how we have tackled this in a very common way. Public health messaging is another important issue. Clearly we have become much slicker at public health messaging and we need to embrace that as we go forward into other public health messages. We also need to focus on our workforce and the changing priorities of our workforce. Society is really changing its priorities and people are asking questions about what are the important things in life. I would obviously say that health and social care should be the priority for any society and I am sure all governments would agree with that, including when they allocate funding.

Mr. Damien McCallion

I will add one or two comments, if I may. Mr. Guckian highlighted the use of technology. Unfortunately, we have all become used to Microsoft Teams and I am sure many here would be glad to see the back of it for a while. The hybrid model, as it has been described, is probably the ultimate utopia.

One of the projects CAWT was using a remote telehealth solution. I will not name the product. This allowed us to accelerate in the south some of the remote technology for use for clinics. We all know of elderly people who were able to avail of this contact, which they might not otherwise have had at the height of the pandemic. This was invaluable. I know our IT people in the south were able to leverage it and use it much quicker. I believe it won an award in recent times. This is an example of how an existing CAWT project using technology to assist in an innovative way was suddenly able to be applied in real time. This is another benefit that came from the work in the pandemic.

From my role in working with Covid in the South, I know it was great to be able to pick up the phone to Mr. Guckian or some of our colleagues in Northern Ireland and have a relationship whereby we could tease through what they were doing. Mr. Guckian spoke about their approach to vaccination in the context of local electoral areas and areas of deprivation. We were able to look and see whether there were things we could learn. If we have learned anything in Covid it is that none of us have all the answers. Collaboration and having these relationships was key to supporting our responses, apart from at a formal public health level with the chief medical officers. There was very strong collaboration at that level also.

Ms Claire Hanna

This has been very interesting. It is clear the witnesses are processing everything and reapplying it as it goes.

Dr. Stephen Farry

I welcome the witnesses. My questions are broad but interrelated to a certain extent. My first is on what is happening with regard to health care reform and the spatial planning in this regard. To what extent are the two jurisdictions on the island speaking to each other about this?. In Northern Ireland we are about to get to grips with the Bengoa reforms. This will involve greater investment in specialisms in certain locations. No doubt there is the same process in the south. To what extent is the process joined up? If it is not, what more should be done to make sure these discussions are happening in an holistic way to really maximise efficiency?

Do the witnesses have views on the health reimbursement scheme? It was approved by the Northern Ireland health board in July last year and will run for a year. It allows Northern patients to access treatment in the south in light of our particular problems with waiting lists with the costs reimbursed. What are the witnesses thoughts on how this is working out in practice? Is it a good idea? Does it cause more distortions in the provision across the island?

Mr. Damien McCallion

From CAWT's perspective the policy side is clearly outside our direct remit. With regard to being familiar with both health care reform programmes, prior to the last lockdown we had plans to bring the HSE and the Health and Social Care Board key teams together to understand where we are all at in areas for collaboration and learning. None of us has a magic potion much as we would wish to have. While we do not have a formal role in this the relationships allow us to have this dialogue. We twice had to cancel a session, prior to Christmas and in January, because of the measures in place at the time. This session was to be between ourselves, the HSE and colleagues in Northern Ireland. While it is not a direct responsibility of CAWT we try to facilitate some of these discussions in the first instance. As we formulate our thinking for PEACE PLUS and the next EU programme we will make sure with both parent Departments that the areas we are looking at are aligned with the reforms mentioned. We will make sure that whatever we try, innovative as it may be, is aligned with overall Government policy in both jurisdictions so we do not do things that are outside it. We want to make sure we are in clear alignment with policy but we are very operational. I will ask Mr. Guckian to comment on some aspects of this.

Mr. Neil Guckian

If the healthcare reforms in Northern Ireland under the Bengoa report are implemented, and if there are further reforms in the southern jurisdiction, where CAWT would be useful is if Border areas are adversely affected. I am very biased and I think of the Western Health and Social Care Trust and the South West Acute Hospital. It goes back to the point made earlier by Deputy Brendan Smith. CAWT can help the two jurisdictions to discuss how the reforms impact in the Border area to make sure Northern Ireland does not make changes that affect the south-west of our area and the southern Government does not make changes that affect the corresponding area. It doubles the impact of access. CAWT can have a role in trying to make sure the Border counties are not adversely affected by the overall impact. This is difficult when we are looking at the impact of two separate decision-making processes and linking it to an EU programme. It is triply difficult. We have to wait until a final decision is made before we can know what the impact will be. We can be even more proactive. It has already been said how passionate I am about helping our links with Sligo particularly.

Dr. Stephen Farry

My family is originally from County Fermanagh so I am acutely aware of the south west. Are there any comments on the health services in the Republic of Ireland reimbursement scheme?

Mr. Neil Guckian

It is important that patients have access to services as much as possible. I am already on record as saying the waiting lists are too long in Northern Ireland. If people can get the services elsewhere and if the Northern Ireland Government can facilitate this then on a personal level I would be very supportive of it. It is a policy decision and will be up for renewal as the time approaches. I hope we can maintain this approach. It is all about treating patients and getting patients treated more quickly. I highlight the work in the South West Acute Hospital where we even brought in the private sector to do 160 hip operations. Normally, bringing the private sector into public buildings would be an extremely unpopular thing to do to but, quite frankly, I do not have that luxury at present when so many people are on waiting lists. We have to think of the patients first. I would like to think of it as a starting point for commissioning more services in the South West Acute Hospital so our unused theatre slots can be commissioned fully. I hope we will continue to be able to demonstrate a fantastic service.

Ms Michelle Gildernew

This has been a great session. It is great to hear about all the work being done on multiple adverse childhood experiences. It is ironic and incredible the research started in the 1940s. The direct correlation between cancer, heart disease and other physical diseases and adverse incidents should be the template for commissioning services. Will the witnesses speak about the work they are doing? It is brilliant it is part of their priorities. If they give us an understanding of what they are doing that would be brilliant.

Mr. Bill Forbes

The project on multiple adverse childhood experiences was initially delayed because of Covid-19. We have appointed a project manager and it is now having a full impact and working extremely well. It has bespoke drawdown contracts for early intervention for children, as opposed to having the most vulnerable in society waiting. It was targeted at children aged from birth to three years and from 11 to 13. We are now covering the entire spectrum from zero to 18 years.

The two frameworks that have been developed allow both jurisdictions to immediately access specialist services for children so they do not go on a waiting list. It is a bespoke contract drawdown. If a child meets the criteria in the assessment tool the practitioner can access the services and there is no delay. It is going really well at present. We gave a presentation on it to the CAWT secretariat only two weeks ago. We have full confidence it will have beneficiaries. The SEUPB has been very supportive. It has extended the programme until May 2023 due to the turnaround of the project and the impact it is having on the most vulnerable in society.

It is a very successful project. Children's services are one of our focuses on the PEACE PLUS project. Mental health and well-being and children's services will be incorporated into that. We are working with the strategy groups on that. We are looking at different age groups through our CAWT strategy groups to see what will have the most impact going forward. Children's services therefore are always at the forefront of our mind, as they are for PEACE PLUS.

Ms Michelle Gildernew

On referral, are these services referred through GPs or through the child and adolescent mental health services, CAMHS? If there are families of whom we are aware who might benefit from talking to the advisers at Co-operation and Working Together, can we refer them?

Mr. Bill Forbes

I would have to refer back on that question about the specific referral pathways. I do not want to be saying the wrong thing.

Ms Michelle Gildernew

Good man.

Mr. Bill Forbes

We are reaching out a lot at the moment. It is usually through the social work teams. In the event that the social workers find a child or family that is vulnerable and that needs support or support at home, we can bring in those specialist services. We can then have an assessment that works out the criteria. Then we would draw down those specialist services very quickly.

Ms Michelle Gildernew

Brilliant, thank you.

Mr. Damien McCallion

We can revert to the committee on the detail. I think it was mentioned that we had an initial presentation from Wales many years ago. That is where the concept came from. It was a good example of how we are able to take something from one jurisdiction and apply it to both our jurisdictions.

My other point is that it is Tusla, and not the HSE, that is the body in the South that is responsible for many, but not all, of the children services. They were able to come on as a partner, although they are not officially part of the CAWT partnership. That is an important point. Although CAWT comprises the statutory bodies, we work with Tusla we work with voluntary bodies and we work with other patient advocacy groups. Many of our projects are involved with the community and voluntary sector as well. Clearly, when looking at things like community health and well-being, its vital not to just look at the statutory sector that is involved. It is another vehicle to engage those sorts of providers to help to deliver the programmes. We can revert to the committee. There is a fair bit of detail in the annual report in the project about where it is at and the geography that is in. It right across the whole Border corridor. It is one of the projects that runs almost entirely across the whole corridor.

Senator Frances Black

First, I thank all of the witnesses for their presentations today. I am blown away by the work that they are doing. It is phenomenal. I thank them for the work that they are doing. They have just answered my question on children services. I wanted to get more of an understanding around the mental health innovation recovery, i-Recovery, piece. Could the witnesses give me more of an understanding of how that all works? That is a specific area in which I have an interest. Could they talk me through it and give me more detail on that?

Mr. Bill Forbes

The innovation recovery project has been extended, with the help of the special EU programmes body, SEUPB, until May 2023. It is a successful project, which sets up a cross-Border mental health recovery college and 12 hubs follow along the Border corridor. Basically, it works in conjunction with the community voluntary sector and with people who have had past experiences with their mental health. Some of the service delivery on that is done, obviously in conjunction with clinical supervision, by people who have had lived experiences of mental health problems. The project empowers people to take control of their own health and well-being again, as well as to look at different pathways and models of support structures that we can put in place. The college currently has 19 programmes online. They focus on anything from stress, help with sleeping and relaxation. We are commissioning another five programmes to go onto that online college, which will bring that programme up to 24. It is accessible online. We have had it move to an ehealth programme. That is where we are. It is running on target. There will be over 10,000 individual beneficiaries of that programme.

Senator Frances Black

That is fantastic.

Mr. Damien McCallion

To add to one or two of those points, 14 of the 24 staff who are working on that programme are people who have lived mental health experience. They are working alongside health professionals. There are six hubs. They are also connected into other initiatives that are running outside of the Border area. Earlier, I mentioned the Kilkenny model, which we visited us as part of that. The operation is called the Kilkenny model and for the recovery college in Kilkenny, the same principles apply on how that is working through. It had to adapt because clearly people could not come into those hubs. As Mr. Forbes said, technology was used to try in some way to maintain a connection with people, challenging though it was. It needed that sort of balance.

As part of the new PEACE PLUS programme, taking the learning from that, we hope to advance more work in mental health. Post Covid-19, we have all seen the impact that Covid-19 has had on people, young and old. We are trying to shape projects that might help us to move out of the experience of Covid-19, hopefully in the years to come, as part of one of our project’s initiatives. We are also building on what is there. What is important from our perspective, as I mentioned earlier, is not to start a project without having some sense of it. The EU funding is time bound. This means that at the end of the programme, well in advance of completion, we must be sure that it delivers value in evaluation and, if it does, that we are well engaged with policymakers and the various processes within our jurisdictions. This is to make sure that we can have funding so that we can at least continue running in the areas where we have it. Ideally, then, we can expand it out to other areas as well.

Senator Frances Black

How would CAWT assess a community service or community organisation? If somebody has a really good programme and they want to deliver it on a cross-Border basis, what steps would be taken, both by CAWT and by them? How does that all work itself out?

Mr. Damien McCallion

Mr. Forbes and Mr. Guckian might also want to comment on this. Our process is that we work with the various partners in the areas that are working around the Border. These obviously include the statutory partners. They will be taking feedback from within their own areas. If I take mental health as an example, we have a working group that is comprised of people from both jurisdictions. We have a chair and deputy chair across the two jurisdictions to get a balance with professionals and experts working in those areas. We look at where the priorities are, how are they aligned to the policies in those jurisdictions, where the focus is in the geography and what the epidemiological, public health or supporting evidence is for it. Then, on that basis, we try to form the priorities. If there are issues within communities, for example, with the mental health services in Cavan and Monaghan, they will be feeding in their experience from those who are working and engaging with those partners at a local level. Then, when we come to deliver the project, we still have obligations under the EU in relation to issues like tendering and so on. We have certain obligations there but we work with community groups to try to support them and to try to make that as seamless as we can.

Mr. Forbes’s team takes the lead on that CAWT, which is the office is based in Derry. They provide that support. To be honest, without that, the partners would not have the capacity or time to deliver. Communities get input through the existing statutory frameworks. Each jurisdiction has its own way of engaging with communities. We do it in the South. Mr. Guckian and Mr. Forbes will want to talk about Northern Ireland. In mental health, we engage with all of the various advocacy groups in looking to develop. There is therefore a lot of legwork involved. Over the past 12 months, we have been building up these ideas. We have been engaging and trying to make sure that it is there before we ever get a call for a tender from the EU under the call for proposals. Therefore, there is a huge amount of preparatory work involved to make sure that we are well aligned in order that when we do submit a proposal, it will be fit for purpose and it will deliver. As well as this, we will know we can deliver it.

Mr. Guckian or Mr. Forbes might want to talk about that consultation process within the sector in Northern Ireland or other examples in CAWT as well.

Mr. Neil Guckian

I will make a brief comment. We need to make sure that it links back to health and social care outcomes first and foremost. When we look at that for mental health services, quite often the engagement of the relevant community can reflect the confidence that people have in the relevant service. Therefore, if individuals do not have confidence in a particular service, our experience is that they will not engage with the particular service. This is about breaking down those barriers. That alone can show that people will have confidence. It is about aligning the outcomes in order that we are able to demonstrate to the EU that a particular project will work. It is also about making sure that we can get the public and the people affected, particularly in services like mental health that have a stigma attached to them, to engage with whatever approach we take and that they can see a lifetime outcome improvement. Would Mr. Forbes like to add to that?

Mr. Bill Forbes

There is constant engagement through the INTERREG VA programme, and the PEACE PLUS, with the community and voluntary sector. We see them as vital to the delivery of the programme, both currently and going forward.

A number of partners from the community and voluntary sector are working with us to deliver services on behalf of the stakeholders through the rigours of SEUPB and the financial constraints of tendering. We envisage full engagement in future with PEACE PLUS. In PEACE PLUS, there must be an emphasis on community and voluntary sector engagement and social prescribing. As part of our programme in PEACE PLUS, there will be full engagement with all sectors of the community to help to deliver on these programmes. It is a very demanding schedule of programmes and with our lack of workforce resources we see them as vital as we move forward into PEACE PLUS. We will recruit these people through workforce optimisation and upskilling the existing workforce so that we can deliver a higher level of service. That is all central to the PEACE PLUS programme.

Senator Frances Black

In CAWT's work on mental health does Mr. Guckian find many legacy issues related to intergenerational trauma?

Mr. Neil Guckian

This is well outside my comfort zone, but the answer is "Yes". In the area of Derry, Tyrone and Fermanagh, which I represent, it is absolutely true for the services we provide. I would also link it to social deprivation. Earlier in the meeting I mentioned that it is the common denominator - social deprivation as well as legacy issues. Multiple layers of social deprivation have massive impacts on outcomes on life expectancy and chronic disease. There are also social care issues. That is where CAWT can have a massive impact for us. It is not just in Derry, Tyrone and Fermanagh. It is also in Donegal and other counties in Border areas. It is a matter of looking behind that and ensuring we can drive forward and improve outcomes.

Mr. Damien McCallion

Part of the PEACE PLUS programme which is bringing together PEACE and INTERREG was also focused on trying to support and deal with some of the legacies from the Troubles. We know the mental health challenges that brings. That will be a key part of the PEACE PLUS programme. We know the challenges with mental health services generally and we need to layer onto that the impact of the Covid pandemic. That is one of the reasons the partners identified mental health as one of our priority areas. We are not necessarily trying to provide all the services; that responsibility lies within the HSE and the various trusts. We are looking for areas where we can add more to it and make a difference.

We have good support across the clinical community, the trusts themselves and the agencies. We know if we are going to try these new ideas, we have a good chance of success because we will only be able to identify certain priorities and we need to zone in and make that work. As I said earlier, if it works, we need to ensure we work with the policymakers and the agencies to try to get that mainstreamed so that the people benefit not just in Border areas but also more widely, both North and South.

Senator Frances Black

Senator Currie mentioned minimum alcohol pricing. It would be brilliant to see that introduced in the North because the evidence shows that it saves lives. I know that CAWT does not really engage with the policy piece, but if it had any influence, it would be greatly appreciated. I thank the witnesses for their presentations today.

Deputy Peadar Tóibín

Gabhaim míle buíochas leis na haíonna as teacht isteach inniu chun cur i láthair a thabhairt dúinn. I thank the representatives of CAWT for all the work they are involved in. There is an awful lot of common sense with cross-Border partnerships and co-operation. From my perspective, the Border is a threat to health in that it reduces the services that people need - sometimes lifesaving services. Erasing those barriers to services is obviously positive for people.

I am trying to quantify what is happening on a cross-Border basis. We often hear of different services that are available. Of the total health services that exist North and South, what is available on a cross-Border basis? Is there a list of health services that are currently delivered on a cross-Border basis? Is it all the services or are some services missing?

Mr. Damien McCallion

In response to parliamentary questions, we would have previously provided Deputies with a list of services. Some services have been developed on a cross-Border basis between both Governments and both Departments relating to, for example, the cardiac PCI service, which allows people with emergency cardiac arrest from Donegal to be treated in Altnagelvin Hospital and we know that saves lives. Mr. Guckian mentioned the cancer services and there are others. Some are very niche and specific. Paediatric cardiac surgery is undertaken in Crumlin on a joint basis. Those are outside our scope, but I am certainly happy to provide a list of them. We have provided it recently through the HSE to Deputies to illustrate the services available on that basis. Those are policy driven.

Through CAWT projects, services are delivered within the jurisdictions by the partners, but we are working together to allow that to happen. That is where the learning and traction come from in terms of those ideas. There are two categories - those that are directly provided and those where we are supporting it. There is also the wider framework that was mentioned earlier, such as the treatment purchase fund or its equivalent in Northern Ireland which allows patients to move between the jurisdictions.

Deputy Peadar Tóibín

Would it be possible to get a list of the services provided by CAWT, the services supported by CAWT and the services provided on a North-South basis? I would exclude the treatment purchase stuff because to a certain extent that can happen anywhere in Europe, does not really have an all-Ireland dimension per se and is often private. I would also like to get a list of what is not provided on a cross-Border basis. As elected representatives, while we should celebrate what has been achieved in the Good Friday Agreement, we really need to focus on what remains to be achieved. Are there figures for the number of patients who receive cross-Border healthcare on an annual basis?

Mr. Damien McCallion

I can certainly provide the list of services. I do not have the numbers. I hate to have to push that to the HSE, which I am a part of. I can certainly work on the HSE to try to get the numbers collectively. We have an EU unit that works with colleagues in Northern Ireland on that. We need to be clear that it is not the role of CAWT. Those arrangements are put in place on a provider-to-provider basis. I can provide the Deputy with a list and certainly an indication of the range of it. They tend to be more specialised services such as the cancer services, radiotherapy and cardiac emergency services that I mentioned. I do not believe the numbers reflect the value. Services such as paediatric congenital heart surgery are crucial services provided on an all-island basis. While the numbers are very small, it took years to develop and has brought benefit to children, North and South. I will certainly provide that list to the Deputy and we can also outline the projects we have and the number of people availing of them in the Border region which would be much larger numbers. However, those are being delivered within, for example, the western trust or the HSE in Donegal, Monaghan, Cavan or in the hospitals.

Deputy Peadar Tóibín

Mr. McCallion will provide figures in general if he can through the HSE and specifically for the services that CAWT provides and supports.

The Good Friday Agreement has been in place for roughly 25 years. When I put questions to Ministers, they talk about InterTradeIreland and the wonderful stuff that is being done on a cross-Border basis. While I agree that these are wonderful things, I am trying to measure them in a quantitative sense as well as the qualitative sense that Mr. McCallion has mentioned. We also need to measure the trends because I want to work out if the number of patients being treated on a cross-Border basis is increasing. Over the past ten years what are the trends with the numbers of patients who are getting services that CAWT provides and supports on a cross-Border basis?

Mr. Damien McCallion

The services that have been introduced in areas like paediatric care, congenital heart disease, ear and throat services and genetic testing - the Deputy mentioned the cancer centre - are quite specialised in terms of numbers. The general trend on usage is that those agreements come into play. All of those agreements have worked well. There are other areas-----

Deputy Peadar Tóibín

Does Mr. McCallion have any figures in regard to the services he has just mentioned?

Mr. Damien McCallion

I can get them. I do not have them to hand. They would be outside the scope of CAWT. They are not something we are directly involved in but I am happy to get them facilitated to the Deputy. We can provide the numbers of beneficiaries. Mr. Forbes has mentioned some of them. I might ask him to give a summary of some of the beneficiaries from the CAWT EU-funded projects for people in the Border region. I might flag that they are time-bound. It was mentioned earlier that if those projects are successful, they are mainstreamed on an ongoing basis. Mr. Forbes will give some headlines around the numbers of people who have benefited from the recent projects.

Mr. Bill Forbes

Our acute framework covers community paramedic, cardiac, geriatrician-led, vascular, dermatology and urology services. Our project target for the current INTERREG programme, VA, was 15,000. The total we had achieved by 31 December 2021 was 16,547. Our CoH-Sync target was 10,000 and we have achieved 10,052. Under MACE, which was referred to, we had a target of 3,125 and we have achieved 2,332, with an extension of that project to May 2023. Our mPower digital project had a beneficiary target of 4,500 and we have achieved 5,077. Our Innovation Recovery project had a target of 8,000 and a total of 5,036 has been achieved so far, with a project extension to May 2023. Over all those frameworks, the project target to 31 December 2021 was 43,134 and we have achieved 41,569. Therefore, we are 96% compliant on the delivery of those services to the beneficiaries we have highlighted.

Deputy Peadar Tóibín

Over how many years is the figure of 41,569?

Mr. Bill Forbes

To be specific, Covid-19 delayed many of the projects. We had letters of offer but the implementation of the projects did not start. For example, MACE was to start in 2017 but was delayed and did not get up and running until the first quarter of 2020. I am quite happy to provide the specific timelines on when the projects were initiated because they had different start times. There were procurement problems and staffing problems and obviously there was Covid-19. I am happy to give the specific project start times-----

Deputy Peadar Tóibín

Is it roughly five years, on the basis that 2017 would have been the start date of some projects?

Mr. Bill Forbes

I would say 2018 or 2019 - probably three years at this stage, to be fair to the projects.

Mr. Damien McCallion

It is about three years, Deputy. There is one cautionary matter I would mention. The projects are innovative. They are targeted at certain communities in small areas. They are not necessarily trying to achieve scale. In fact, it is almost the opposite. Their objective is to try to prove that the innovation, or concept, works. I mentioned the community paramedic project. We had two community paramedics - one in the Inishowen area of Donegal, and I think Monaghan was the other county in the South. Then there was Tyrone in Northern Ireland, and Scotland. Six individual people were trained for 12 months. It was a big commitment by those individuals. They were then able to take referrals from general practice that avoided people having to get an ambulance to take them to hospital, or make a 999 call. They were able to assess whether people needed to go to hospital. It was very much about trying to do that innovation. The numbers might be relatively small but, having proved it works, it has been taken on by the ambulance service, which is trying to extend it into other areas. Our role is not about achieving scale, in terms of what we are trying to achieve with the EU. The EU projects are very much focused on innovation and learning and then trying to move those into the mainstream.

Deputy Peadar Tóibín

Scale is very important to me, although I appreciate that it might not be part of CAWT's mandate. I fully respect that CAWT is fulfilling its mandate. However, scale is important. Obviously, there are 1 million people on health waiting lists in the South, and 250,000 people in the North are on health waiting lists for over a year. How do we scale up the delivery of services on a cross-Border basis to actually reduce those waiting lists?

Mr. Damien McCallion

That is not an issue for CAWT. I appreciate the general point. There are challenges in both jurisdictions. Both of them have seen increased waiting lists in the past number of years. Our role is not essentially in relation to mainstream services. Our role relates to looking at innovation, looking at projects and programmes that can deliver benefit and trying to get them mainstreamed in line with the Deputy's question on how to get them into the system. That is our focus and our mandate. Responsibility for waiting lists in the South is within the HSE and in Northern Ireland is within the relevant trust or the Health and Social Care Board. We do not play a direct role in that. We can facilitate that through some of the innovations and ideas I mentioned earlier by trying to look at things that might work and to support both jurisdictions. We have a different role. Our mandate is not to get directly involved in the day-to-day operations of the services; it is really just to try to deliver programmes that can provide benefit. I ask my colleague Mr. Guckian to comment from Northern Ireland.

Mr. Neil Guckian

We can only do that when the EU funding aligns with the target we are looking to achieve. CAWT is looking to avail of EU funding to help and boost the core services. If we can align the outcomes with the EU targeted outcomes, we can tackle the waiting lists accordingly. We have done that to degrees in regard to various specialties. Mr. McCallion is right when he says it is about making sure we identify innovation which can be spread across the jurisdictions.

Deputy Peadar Tóibín

Mr. McCallion mentioned community paramedics. Again, this question might not relate specifically to CAWT's mandate. It may do, however. Is there a cross-Border ambulance service? Is that a possibility? There would obviously be a benefit in it, considering it can be very difficult to get an ambulance in a Border area. Does CAWT's remit function in that space?

Mr. Bill Forbes

Memorandums of understanding have already been signed off and agreed between the National Ambulance Service in the South and the Northern Ireland Ambulance Service in Northern Ireland. There is mutual working between those services. Both services work on a daily basis to ensure a timely response, or a more timely response, to a 999 call. There would be daily workings between both jurisdictions. The National Ambulance Service in the Republic of Ireland may ask for the assistance of the Northern Ireland Ambulance Service when it is geographically closer to respond to a call, for example in the Inishowen area of County Donegal. That happens on a regular basis, and vice versa. The National Ambulance Service provided significant resources when the Northern Ireland Ambulance Service was under extreme staffing pressures. That works very well.

Deputy Peadar Tóibín

Is there any co-operation with regard to air ambulance services?

Mr. Bill Forbes

Medevac 112 in the Republic of Ireland is a military aircraft and does not have clearance to go into Northern Ireland as a military aircraft. The Northern Ireland Ambulance Service runs an air ambulance that does have clearance and will respond into Inishowen and elsewhere in the Republic of Ireland, if so requested.

Deputy Peadar Tóibín

Unfortunately, the southern one cannot enter the northern airspace, but the northern one can enter the southern airspace.

Mr. Bill Forbes

Yes, but the HSE has a contract with the search and rescue services and they respond on a cross-Border basis as well.

Deputy Peadar Tóibín

Covid-19 was obviously the biggest health threat to the island of Ireland over the past two years. Again this may be outside CAWT's mandate, but there were two separate approaches to restrictions and two separate vaccination programmes. Everything was disjointed between North and South. There were times when illness raged in the North and was lower in the South, yet we saw when Derry was extremely affected by Covid-19, Donegal, especially Inishowen, was extremely affected too. When the North was at a high wave, Monaghan and Cavan were also showing very high figures.

Unfortunately, neither administration stepped up to the plate in a joint approach to Covid-19 in that regard. Is there anything that can be done by the likes of the group before us to foster a better island-wide approach to a pandemic such as this?

Mr. Damien McCallion

From the perspective of CAWT, I would not have a direct role, but I am also in the HSE working on our Covid-19 response so I have a couple of observations. At the departmental level, the two Chief Medical Officers would have worked very closely at recognising some of the matters mentioned by the Deputy. There was a joint memorandum of understanding put in place and I know there was regular contact, with regular calls and meetings, as various stages of the pandemic unfolded, as the Deputy noted.

At an operational level we also worked closely with colleagues in Northern Ireland around some of the challenges mentioned by the Deputy, whether that was around our testing or vaccination strategies. There was constant dialogue and where CAWT had value is that we had those relationships. I could pick up the phone to Mr. Guckian or the chief executive of the Health and Social Care Board and speak with leads there about certain areas. There was much co-operation at operations level and at policy level with the Chief Medical Officers. That is outside our remit but I should articulate it. Mr. Guckian might want to comment on how people along the Border engaged at a local level.

Mr. Neil Guckian

I have a wider point going back to the answer we gave to Ms Hanna, which is that there is much learning to be done from this pandemic at the level of both jurisdictions and in organisations such as mine in how we organise and respond to the needs of the population. There is learning to be done in how the public messaging can be co-ordinated. It is something we must consider as feedback from the pandemic.

I totally agree with the Deputy. It was interesting to watch as when Derry got into a major spike, it was exactly the same issue for Donegal. There were clear times when the Border regions had Covid-19 infection rates that accelerated at a different rate from the rates in the capitals. That was a real challenge to local services such as mine. It is something we should reflect on.

Deputy Peadar Tóibín

Is there any institutional investigation happening in the North on the delivery of policies against Covid-19? Other countries are having investigations or reviews. Is that happening in the North?

Mr. Neil Guckian

Yes, I am sure there will be reviews in Northern Ireland, like any other country. We have quite a lot of reviews so I am sure we will have reviews about the handling of Covid-19.

Deputy Peadar Tóibín

I thank the delegation for the information it has provided. I greatly look forward to some of those quantitative responses. It will provide food for thought for all of us on this committee.

Senator Niall Blaney

The witnesses may reply via email but I forgot to ask about neurology services in the north west. It is a particular concern in Letterkenny and Sligo, especially with regard to equipment. That would take in Derry as well.

Ms Michelle Gildernew

I am not sure if Deputy Tóibín is still there but we are talking about Border communities and dispersed rural regions. If we go down the route of quantifying numbers and all of that, we would do those communities a disservice. People in those communities have had to travel to Belfast, Dublin or wherever for services in the past. If people are judged on numbers, they will do what they do. I want to make that point and I thank the witnesses for the work they do to deliver services in my community. It is vital that they focus on the areas of work and what they are able to do rather than necessarily the numbers of people being helped.

Chairman

I thank Mr. McCallion, Mr. Guckian and Mr. Forbes. It has been a very enlightening and informative session. That sense of co-operation brings hope in moving things forward. We look forward to receiving their data and the annual report and so on. I thank the witnesses.

The joint committee adjourned at 3.55 p.m. until 1.30 p.m. on Thursday, 17 February 2022.