1. Shared health services on the island of Ireland
Strand 2 of the Good Friday Agreement 1998 provides for the creation of the North/South Ministerial Council to facilitate cooperation between Northern Ireland (NI) and the Republic of Ireland (RoI) and currently covers collaboration on various cross-border healthcare services.
The Department of Health NI expects that all cross-border services which are arrangements between NI and the RoI under this framework to continue unaffected as they do not rely specifically on EU legislation to function. This includes the Paediatric Congenital Heart Service and many others.1
We call on the UK Government and NI Department of Health to clarify how all-island healthcare services will continue unimpeded in the event of a no-deal Brexit when provision will no longer be underpinned by EU law on the free movement of people and services and the possibility of land border barriers regulating the movement of goods.
2. Free movement of people
The introduction of the EU Single Market in 1993 resulted in the closure of customs posts on the Irish border.2 Post-Brexit, the internal Irish border will become an external border. The Centre for Cross Border Studies estimates that between 23,000 and 30,000 people are cross-border workers.3 The CSO Cross Border Commuters 2016 Report shows significant movement from RoI to NI in the following regions: Donegal to Derry, Monaghan to Armagh and Cavan to Fermanagh. Overall, from all industries surveyed crossing the border to access work, approximately 19% are health and social work professionals.
In the event of restriction on movement, impact would be felt acutely in NI hospitals; Daisy Hill, Altnagelvin and SWAH which serve border communities.4
It is imperative that there is no impediment to the free movement of people on the Island of Ireland.
2.1 Common Travel Area (CTA)
CTA rights set out in UK government guidance include: the right to enter and reside in each other’s state without being subject to a requirement to obtain permission, the right to work without being subject to a requirement to obtain permission and the access to health services.5 The CTA is a series of mutual understandings between the UK and Ireland that accord UK and Irish nationals these rights.
While the CTA immigration regime enables all Irish and UK nationals to ‘work’ in each other’s jurisdictions without specific visa permission, this is a general entitlement, and is not equivalent to the ‘right to practice medicine’, the rules that coordinate mutual recognition of qualifications (specialist registration) originate in Directive 2005/36/EC.6
2.2 Mutual recognition of qualifications
EU Directive 2005/36/EC currently allows for Irish and UK citizens to have professional qualifications recognised. Both jurisdictions have confirmed that in the event of a no deal Brexit UK qualifications already recognised in Ireland will continue to be recognised and vice versa.
However, in the event of a no deal Brexit, applications for UK qualifications to be recognised in Ireland will be processed as ‘third country’ applications meaning the process will take longer.7 It is likely that in lieu of Directive 2005/36/EC and automatic recognition, there will be longer processing timelines for RoI applications to NI as a UK region.
This is problematic since it is estimated that 72% of EEA graduates in NI gained their PMQ in the RoI8 and may have completed their specialist training in the RoI also. It is also problematic for the future delivery of shared services where doctors travel to different sites across the Irish border.
2.3 Driving cross-border
NI Direct Government Services advises that in the event of a no deal Brexit, NI licence holders will have to have a motor insurance green card from their insurance company to drive in the RoI. It is advised that it may take between 15 days to one month to process the request for a green card and that this time should be factored in before travelling. An International Driving Permit will not be required in any eventuality.9
We call on the UK Government to:
- work to ensure that no physical border infrastructure or non-tariff barrier is established at the Irish land border which would indirectly impede the free movement of healthcare workers or patients
- codify the Common Travel Area associated rights by bilateral agreement and/or new legislation
- work with the GMC and Medical Council of Ireland to achieve a streamlined system of recognising medical qualifications to ensure that going forward registration is not subject to undue delay.
3. EU funding
NI and RoI border counties have benefitted greatly from sources of EU funding, mainly INTERREG and PEACE. The region was allocated €283m of INTERREG VA Programme funding (2014-2020) designed to help overcome the issues relating to the existence of a border. €240m was provided through the European Regional Development Fund, the remaining €43m was match-funded by the Irish Government and the NI Executive.
The content of this Programme has four core objectives which includes providing health and social care services on a cross-border basis which ideally will be mainstreamed into core services after the funding period. Various services have been rolled out by Cooperation and Working Together including Childhood Multiple Adverse Childhood Experiences programme which secured €5.01 million and the Acute Hospitals Services project ‘Connecting Services, Citizens and Communities’ which secured €10 million have been established through this funding.10
Since the Good Friday Agreement in 1998 the region has received PEACE funding from the Special EU Programmes Body (SEUPB) designed to support peace and reconciliation. The most recent round, PEACE IV invested €270m, €229m was provided through the European Regional Development Fund the remaining €41 is match-funded by the Irish Government and the NI Executive. This funding is inextricably linked to mitigating the social determinants of mental and physical health and wellbeing in this region.
The SEUPB recently clarified that even in the event of a no-deal Brexit, funding under the current PEACE and INTERREG programmes will continue until conclusion in 2023. It is anticipated that funding programmes will continue after Brexit through a single PEACE PLUS programme as part of the EU funding budget 2021- 2027.11 The UK Government has given their commitment to the PEACE PLUS Programme and it is hoped that sufficient allocation of funds will be forthcoming regardless of how the UK exits the EU.
We call on the UK Government to allocate sufficient match funds to meet Northern Ireland obligations under the PEACE PLUS programme (2021-27) to enable the continuity of regional stability and shared health and social care services and consider how funding will continue post-2027.
4. Department of Health Northern Ireland advice and guidance
The Department of Health website details their operational readiness plans for the possibility of a no-deal exit from the EU.12
Action cards have been forwarded to all HSC providers covering: Communications and methods of escalation; Reporting; Assurance and information; Supply of medicines and vaccines; Supply of non-clinical consumables; Goods and services; Workforce; Reciprocal healthcare; Research and clinical trials; Data Transfer Risks and Finance.13
On Brexit related issues, the Department of Health are contactable at EU.Exit@health-ni.gov.uk.
- 1. Letter from to CEs of HSC Trusts and HSC Board (11 September 2019) available at: www.health-ni.gov.uk/sites/default/files/publications/health/eu-exit-update-110919.pdf
- 2. NI Affairs Committee (13 March 2018) The land border between Northern Ireland and Ireland, available at: publications.parliament.uk/pa/cm201719/cmselect/cmniaf/329/329.pdf
- 3. NI Affairs Committee (13 March 2018) The land border between Northern Ireland and Ireland, available at: publications.parliament.uk/pa/cm201719/cmselect/cmniaf/329/329.pdf
- 4. Central Statistics Office (2016) Cross-border Commuters available at: www.cso.ie/en/media/csoie/newsevents/documents/census2016profile6-commutinginireland/Cross_Border_Commuters_2016_v2.pdf
- 5. House of Commons Library, Northern Ireland, Citizenship and the Belfast/Good Friday, available at: researchbriefings.files.parliament.uk/documents/CBP-8571/CBP-8571.pdf
- 6. Northern Ireland Human Rights Commission and the Irish Human Rights and Equality Commission (2018) Discussion Paper on the Common Travel Area available at: www.nihrc.org/uploads/publications/Discussion_Paper_on_the_Common_Travel_Area.pdf
- 7. Medical Council Ireland, Brexit Information in event of a No Deal Scenario, available at: medicalcouncil.ie/Registration-Applications/Brexit
- 8. GMC (2017) Our data about doctors with a European primary medical qualification in 2017, available at: www.gmc-uk.org/-/media/documents/gmc-data-about-doctors-with-eea-pmq--november-2017--final_pdf-72545961_pdf-74307617.pdf
- 9. NI Direct Government Services ‘Driving in the EU and EEA after Brexit’, available at: www.nidirect.gov.uk/articles/driving-eu-and-eea-after-brexit
- 10. Cooperation and Working Together Annual Progress Report 2018, available at: www.cawt.com/download/doc_library/corporate/CAWT-APR-2018-FINAL_2.pdf
- 11. Letter from Gina McIntyre, CEO Special EU Programmes Body SEUPB to Stakeholders and Beneficiaries, available at: www.wheel.ie/sites/default/files/media/file-uploads/2019-09/SEUPB_Stakeholder_Correspondence_19.09.19.pdf
- 12. Department of Health Operational Readiness, available at: www.health-ni.gov.uk/department-health-ni-eu-exit-operational-readiness-guidance
- 13. Department of Health (NI) EU Exit Operational Readiness Guidance, available at: www.health-ni.gov.uk/department-health-ni-eu-exit-operational-readiness-guidance#Annex%20A