Seanad Special Committee on the Withdrawal of the United Kingdom from the European Union debate -
Thursday, 8 Jun 2017

Engagement with British Medical Association and Irish Medical Organisation

Chairman

We are now back in public session. I thank the witnesses for their patience. It looks like we will be continuing through lunch so we have all had to re-juggle our office agendas a bit. I am delighted to welcome representatives from both the British Medical Association Northern Ireland Council and the Irish Medical Organisation. Their contributions today will be very timely and will feed in what has been a marathon series of sittings of this committee, leading into a report that is starting to resemble 17 volumes of a phone book at this stage, though we might try to slim it down. We have been looking at seven key sectoral areas, the eighth being the future of Europe. This is the seventh, not through preference but as dictated by the time it took to get everyone that we wanted here. We are really looking forward to witnesses' contributions this afternoon and to a few follow-up questions. Please bear with me as I read the note of privilege before we begin.

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

With that out of the way I invite Dr. John Woods to make his opening remarks. When he is finished I will go straight on the next witness and we will then take questions at the end.

Dr. John D. Woods

I thank the Chairman and the committee for that welcome. I begin by thanking the committee for the opportunity to come here today and give evidence on behalf of the British Medical Association in Northern Ireland and to outline the potential impact of Brexit on doctors and patients on both sides of the Border. I appreciate that some of the committee are perhaps less than familiar with the BMA. The BMA is an apolitical organisation. It has the dual functions of being both a professional association and a trade union. We represent 160,000 doctors and medical students across the UK and have more than 5,500 members in Northern Ireland.

Northern Ireland's health and social care system, similar to that of the Republic of Ireland, is currently under unprecedented pressure, trying to meet the needs of a growing population with increasingly complex illnesses against a backdrop of strict financial constraint. BMA Northern Ireland is very concerned at the UK's decision to leave the European Union and believes that unless appropriate agreements are implemented, there will be a substantial negative impact on doctors' working lives. This will detrimentally affect patient care on both sides of the Border.

Given the committee's familiarity with this issue I will be try to be concise in outlining what we see as the direct challenges to the medical profession in Northern Ireland and how we think these challenges should be met.

The first significant challenge we have identified is the threat to effective cross-Border co-operation in providing health care. Northern Ireland and the Republic of Ireland are smaller health economies and both have difficulty independently providing some highly specialist services efficiently. By pooling our resources, we can provide high-quality specialist care across the island. In recent years, such services have been developing and are providing significant benefits for patients throughout Ireland.

An example with which the committee is familiar is the paediatric cardiac surgery service based in Crumlin in Dublin, which enables children from Northern Ireland and the Republic of Ireland to receive treatment for heart conditions without having to travel abroad, and there are others. I am a consultant kidney doctor and my colleagues on both sides of the Border are exploring whether it is possible to provide some very specialised kidney transplant services together.

Our health services also co-operate in providing high quality medical care to patients who live close to the Border. Good examples are in cancer care and cardiac care. The new radiotherapy unit in Altnagelvin Area Hospital in Derry will provide access to radiotherapy services for over half a million people in both Northern Ireland and the Republic of Ireland. A cardiology service based at the same hospital provides primary angioplasty, which is the best treatment for heart attacks, for patients in Donegal and saved 27 lives in its first nine months of operation. These services directly benefit Irish citizens living in the north west of Ireland. The existing open Border arrangements facilitate such co-operation between our health services.

The committee is aware of the Cooperation and Working Together, CAWT, project and the role it plays in funding cross-Border health and social care initiatives, and of the EU's related projects via the PEACE and INTERREG funding programmes. Between 2003 and 2015, more than €40 million was invested in cross-Border health and social care initiatives through CAWT. Additional project applications, amounting to €53 million, have been submitted for a wide variety of health-related services. The UK’s future financial liabilities to the EU and participation in its funding programmes are a matter of some sensitivity and debate. However, given the relatively small sums involved and the return on investment see, we ask that the Irish and UK Governments give serious consideration to continuing funding of such initiatives after Brexit.

Another issue is cross-Border workers. Committee members are aware there are literally thousands of cross-Border workers in Ireland. More than 13,000 people live in the Republic but work in the North, returning home daily or weekly, and more than 3,000 people from Northern Ireland do the reverse. Many of these people work in health care and make a very important contribution, particularly in Border areas. Cross-Border co-operation and the delivery of health care, particularly in Northern Ireland, would be impossible without the free movement of these people. To secure our ability to continue to provide high quality health care we need to put in place agreements to permit the ongoing free movement of doctors and health care workers. Maintenance of the common travel area would enable health professionals based on both sides of the Border to travel freely to work and to co-operate in joint initiatives.

I am less familiar with workforce issues in the Republic of Ireland, but Northern Ireland faces some critical shortages of doctors, particularly in primary and secondary care. Doctors who obtained their primary medical qualification from other EU states are an important part of the medical workforce in the United Kingdom. For those doctors, concerns about their future residency status and rights mean that many of our members from other EEA states are planning to leave. The BMA recently carried out a survey of our members in this position throughout the UK. We tried to shed further light on their experiences and perspectives. These European doctors make up approximately 7% of doctors in the NHS. Of the 1,200 respondents, four out of every ten EU doctors reported that they were considering leaving the UK post-Brexit. The resolution of this issue is, for once, relatively simple. Permanent residence should be granted to EEA citizens working as doctors in the UK, and vice versa, even if they have been resident for less than five years. Michel Barnier, who spoke to the Oireachtas last month, shares this view and has specifically referenced this issue as a priority within the negotiations.

Another challenge we face is mutual recognition of professional qualifications. A total of 9% of the doctors in Northern Ireland secured their primary medical qualification in another EEA state, with a large number of these doctors having qualified in the Republic of Ireland. Mr. Molloy mentioned the welcome Irish universities extend to students from Northern Ireland and I am one of the people who benefitted from this. I went to Trinity College. There are also doctors from the UK who work in Ireland. They account for approximately 4% of the total number of doctors registered with the Medical Council of Ireland. We understand that an extension of the EU directive is unlikely, but the European Commission's recently published draft negotiating directives state "the withdrawal agreement should continue to provide the same level of protection for EU citizens in the UK and UK citizens in the EU" and specifically referenced recognition of diplomas, certificates and other qualifications. We hope this provision will be agreed and will include medical qualifications. Failure to do so would threaten Irish students' ability to practise medicine in their home country or elsewhere in the EU, and could prevent Northern Irish students currently studying medicine in the Republic from returning home to practise. This would certainly have a detrimental effect on workforce planning and threaten the diversity of our medical schools.

At present a variety of patient safety measures exist. These depend on the mutual sharing of information across Europe. A good example of this is the sharing of information between European regulators when restrictions are placed on a doctor's ability to practise. We believe it is imperative that such safety measures, and other efforts to ensure minimum standards in medical education and training, are maintained and agreed between the respective regulatory and educational authorities.

I appreciate that time does not allow me to go into greater detail, or cover all of the issues impacting the medical profession, but I hope the written evidence BMA Northern Ireland has also submitted will be useful in addition to my contribution today. I thank the committee for its time and I am happy to take any questions.

Chairman

I thank Dr. Woods for his sincere and in-depth remarks. I welcome him and his colleague, Mr. Laffin, to this afternoon's session. Our next presentation is from the Irish Medical Organisation. I welcome Dr. Ann Hogan and her colleague, Professor Trevor Duffy.

Dr. Ann Hogan

The Irish Medical Organisation, IMO, thanks the Chairman and members of the Seanad Special Committee on the Withdrawal of the United Kingdom from the European Union for the opportunity to come before it today.

The Irish Medical Organisation is the representative body for all doctors throughout Ireland. The organisation has close ties with our colleagues in the British Medical Association. Like our colleagues in the BMA, the members of the IMO have serious concerns about the impact the United Kingdom withdrawal from the European Union will have on the health and isolation of people living in the Border areas and on co-operation in health care delivery, especially between Ireland and Northern Ireland as well as between Ireland and the rest of the United Kingdom.

Membership of the European Union has facilitated co-operation between Ireland and Northern Ireland in the area of health care. The Cooperation And Working Together partnership between health and social care services in Ireland and Northern Ireland has facilitated several successful collaborative projects in health care in the Border regions by managing funding from the EU INTERREG programme and the Special EU Programmes Body. Approximately €47.5 million worth of EU INTERREG VA funding has been provided to support cross-border projects involving Ireland, Northern Ireland and Scotland until 2020. The projects supported include those aimed at the enhancement of acute services through new technology and e-health solutions, mental health services, supported living, early intervention services and projects aimed at reducing inequalities in health.

Under the EU INTERREG IVA programme 53,000 people in the Border areas benefitted from health and social care services. EU funding of €30 million supported projects in the areas of alcohol, sexual health, diabetes, obesity, eating disorders, autism and disability services. While many of the projects have been limited in duration, the majority have resulted in longer-term service level agreements. These agreements include: the provision of general practice out-of-hours services in Castleblayney in County Monaghan and in Inishowen in County Donegal; shared dermatology clinics at four sites along the Border; ear, nose and throat services at Monaghan Hospital as well as Daisy Hill Hospital and Craigavon Area Hospital in Northern Ireland; and renal services at Daisy Hill. Other cross-border service level agreements exist as a result of collaboration and capital investment from both sides of the Border, including radiation oncology services and emergency cardiology services at Altnagelvin Area Hospital and the provision of all-island paediatric cardiac surgery services for children with congenital heart disease at Our Lady's Children's Hospital Crumlin, Dublin.

The HSE currently purchases a number of high-tech treatments from the UK, including organ transplantation and treatment for lymphoedema. The HSE also purchases care from Northern Ireland and Great Britain under the waiting lists initiative and on a case-by-case basis, including 574 patients who received treatment in the UK under the treatment abroad scheme.

Significant scope exists to further develop services on an all-island and cross-border basis, especially in the area of high-tech tertiary care and in the management of rare diseases. There is also scope to further fill gaps in services to the Border areas. We estimate there are 30,000 frontier workers, many of whom are entitled to access care in both jurisdictions, while all Irish and UK citizens are entitled to access necessary care while temporarily in each jurisdiction with a European health insurance card. An increasing number of patients have taken advantage of the patients' rights in cross-border care regulations with 700 patients accessing care in Northern Ireland last year.

Of necessity, cross-border co-operation exists in the area of public health, especially in the area of health protection. It is essential for the health of the populations on both sides of the Border that this cross-border co-operation continues, especially in the areas of control of outbreaks of infectious diseases, which may have a cross-border dimension, and in emergency planning and response.

Currently, a total of 3,196 doctors who received their primary medical degree in Ireland are registered with the General Medical Council in the UK while 742 doctors who received their primary medical degree in the UK are registered with the Medical Council in Ireland. Many Irish graduates complete their post-graduate training or spend a period in the UK before returning to Ireland, although increasingly, fewer are returning.

The UK departure from the EU will have a significant impact on health and access to health care, particularly in the Border regions. A total of 1.6 million people live in the Border regions. The economic impact of Brexit will increase deprivation rates and isolation, with consequent impact on the health of individuals in the Border areas. The greatest challenges posed by the UK withdrawal from the EU will include ensuring ongoing and future collaboration in the field of health care as well as timely and seamless access to care for patients in Border areas. We cannot be complacent and assume that co-operation will continue in future once the UK has left the EU. Political interests and issues of funding may impact negatively on access and cost of care for patients on both sides of the Border. While INTERREG VA funding has been guaranteed to 2020 there is no guarantee yet of funding thereafter. We know that in the short term EU social security arrangements are to stay in place but in the medium term the rights of cross-border workers and patients' rights to access treatment on a cross-border basis are unclear. Regardless of how hard, or soft, a border will be in place in future, impeding the free movement of patients, ambulances and doctors across the Border will be problematic. Common European regulations relating to pharmaceuticals, medical devices and data protection may no longer apply. Legislation which has aided the movement of health care professionals may no longer apply. In addition, the rights of doctors to work in both jurisdictions and the automatic recognition of medical qualifications will no longer apply. Bureaucracy will affect the flow and training of medical professionals between jurisdictions.

Planning must begin immediately to ensure that patients, especially those in the Border regions, have ongoing access to vital health and social services. The IMO believes that, rather than adopting a wait-and-see attitude, careful planning is required to ensure that collaboration in the area of health care continues and develops in future. We recommend that a cross-border committee be established to examine the impact of Brexit on existing and future cross-border health services and to ensure that watertight agreements are in place for collaboration in future. The committee should include relevant decision-makers within each jurisdiction as well as stakeholders with practical experience. For each collaborative arrangement, every possible future scenario should be developed to assess potential risks and barriers to patient care that may develop and to ensure that pathways for accessing services, treatment and follow-on care are seamless. Long-term cost and funding arrangements for current and future collaborative projects must be secured. Mechanisms must be put in place to ensure that patients, ambulances and health care professionals in both jurisdictions can move in a timely manner across the Border. Where EU legislation has facilitated cross-border health care, bilateral agreements must ensure ongoing co-operation. For example, regulatory bodies in Ireland and the UK should work closely together to ensure the recognition of qualifications and to facilitate the movement of medical and other health care professionals across jurisdictions to avoid duplication of legal requirements.

Future regulatory requirements must ensure that high standards are maintained in respect of medicines, medical devices and food safety. Arrangements must ensure that prescriptions written by medical professionals on one side of the Border are recognised on the other side. Future regulatory arrangements and eHealth standards must ensure that patient data can be securely transferred between health care settings from one side of the Border to the other side. Finally, the North-South Ministerial Council should develop a proactive strategy to ensure ongoing and future collaboration in the development of cross-border and all-island health care services.

Chairman

Thank you, Dr. Hogan and Dr. Woods. I have two questions that you might be able to address. One relates to the last comment you made, Dr. Hogan, in respect of the potential for the North-South Ministerial Council and the context of where we are now in terms of UK-Irish relations and the reliance on the Employment, Social Policy, Health and Consumer Affairs Council and the various other forums for discussion and agreement. Is the North-South Ministerial Council the best way to replace the ongoing discussion at ministerial level? What do you imagine would be needed to expand that role?

My second question relates to a comment we heard earlier from representatives of the INMO. They referred to the European Medicines Agency, the ultimate relocation from London to somewhere else and the ongoing bid from Dublin to attract the EMA to Dublin.

We know what the positive impacts of that, from the perspectives of both employment and the economy, on the region would be but if it was to come to Dublin, what would it mean, either positively or negatively, to either organisation and those they represent? Does either of my colleagues want to add anything to that?

Senator Paul Daly

I will take up one point Dr. Woods made. He stated four out of every ten doctors in the UK have indicated the possibility of moving on or leaving. What detrimental effect would that have? While we are here to formulate a report and steer matters from this side, the UK's problems are not our problems but they are our problems. I was intrigued by that. Did they give reasons as to why they indicated that?

I will elaborate on the Chairman's question on the problems these organisations foresee with regard to regulation, in particular, drug regulation, drug standards and new drugs perhaps being accepted in a new UK and not here. Irrespective of the cross-Border issues they mentioned, what issues may arise in that regard? In the greater scheme of things down the line, what is the possibility of certain drugs not being available in the North which would be available, accessible or sanctioned in the South, or vice versa, and can they see that creating problems for those with rare diseases in one jurisdiction wanting to access such drugs from the other?

Senator Michelle Mulherin

I thank the witnesses for their presentations and practical recommendations.

I have a question. We had Liam Doran of the INMO here earlier and he foresaw that the issue of Brexit would accelerate the drive to bring more health care professionals, particularly nurses and midwives, to the UK because it is not supplying its own to meet its needs. With our doctors leaving, it is a problem. Do they envision that there will be an increased number of doctors leaving or will Brexit, or the other factors, play into that? Also, although it is not quite strictly Brexit, how do we keep our doctors?

Chairman

It is absolutely strictly Brexit. I ask Dr. Woods to respond first, and then Dr. Hogan.

Dr. John D. Woods

On the subject of the Chairman's question on the EMA, it is certainly clear that having the EMA in London has been positive for the UK pharmaceutical industry and for medical research in the UK. It is clear it will leave. If it comes to Dublin, we would view that positively from the point of view of Northern Ireland because, as was outlined earlier, there are very significant collaborations in terms of medical research between universities, North and South, and anything that would benefit that would be of benefit to us all.

When I talked about the four-tenths of doctors who would eventually leave the UK, those are European graduates. European graduates make up 8% of the medical workforce overall in the United Kingdom but of those, just under half have said that they would potentially leave. The first problem for them is insecurity, for instance, as to whether they will even be entitled to residency. That is why one of our asks was for them to be given guaranteed residency in the UK. I suspect another problem is that many of those are doctors in training who are gaining UK postgraduate qualifications which, until now, have currency throughout Europe. If those postgraduate qualifications were no longer recognised, for instance, by the Greek medical council, I would foresee it would be less attractive to them.

The Chairman was quite right about the issue of innovative new drugs. I see this as a problem for us rather than for Ireland because Ireland will still be in the European medicines regulatory framework. However, we will be stepping outside of that. We will be a small market then. I would anticipate that major pharmaceutical companies will be much less likely to go through the rigorous process early of licensing their new drugs. For us in the UK, it will mean that we will gain access to new innovative treatments later than we would at present. It is a problem for us rather than for Ireland.

Senator Mulherin talked about doctors leaving Ireland being attracted to the UK. We see the problems being the reverse. We are concerned that lots of Irish graduates who are working in the UK currently will come back to Ireland and will not want to work in the UK. As I stated, doctors who graduated in another EU country contribute 8% of our workforce in medicine overall and we desperately cannot do without them. In some specialties, particularly surgical specialties such as obstetrics and ophthalmology, 15% of the doctors are graduates from other European countries, including Irish graduates, and we cannot fill those positions currently without those doctors.

Dr. Ann Hogan

To follow on from the issue of the doctors, an awful lot will depend on the recognition of qualifications. If Irish doctors working in the UK are in training and the qualification concerned will not be recognised in other EU countries, they may well leave the UK, but then if the qualifications are recognised, who knows what will happen? There has traditionally been considerable movement of Irish doctors back and forwards to the UK for training and for longer-term work, as there has been with all kinds of Irish workers, but increasingly, Irish doctors are going further afield to other English-speaking countries. They are going to Australia, Canada and the US also. The UK is not the main market for Irish graduates, whereas it used to be.

On the question about the North-South Ministerial Council, I suppose if the UK is leaving the EU, because of the UK being our closest neighbours and that making it practical for us to collaborate on many issues, particularly in relation to rare diseases, and also due to part of the UK being part of our island where collaboration in all areas makes the most sense, negotiating bodies at every level will have to be established between us and the UK to replace negotiations that would have gone on at European level in the past because it is too important to both populations to let those connections die.

Does Professor Duffy want to add anything?

Professor Trevor Duffy

If I may?

Chairman

Of course.

Professor Trevor Duffy

I suppose I have a couple of comments. First, on the North-South Ministerial Council, very much as Dr. Hogan has said, it will certainly have a much more significant role, but it is important to see this as not only a North-South issue. A significant component of our health care co-operation exists with mainland UK also. For example, historically, one thinks of transplant programmes, such as lung transplant programmes that would have worked through places such as Newcastle. That council could probably do with being broadened to work across the UK.

Taking both drug regulation, availability of new innovative products, etc., and the EMA together, undoubtedly, if the EMA were to relocate to Ireland, it would have all sorts of positive knock-on effects, not only economic. Specifically, within health care, one would hope it would give Ireland a reasonable voice at the EMA. If it leaves London and goes to mainland Europe, we would certainly have to fight to maintain a voice at the EMA.

If the EMA resides in Ireland, one would hope it would have a knock-on impact on clinical trials that happen in Irish hospitals. Currently, the clinical trial activity within the hospital sector is probably 30% of what happens in comparators, such as Denmark. There is clear, well accepted evidence now that research-active hospitals, that is, hospitals that engage in not simply education but clinical research, have significant mortality and morbidity advantages over non-research active hospitals. It is a strong drive for organisations, such as the HRB, to increase trial activity.

The European Medicines Agency would have significant positive knock-on effects all the way through to new drug opportunities and availability. While I put my hand up here as being quite ignorant of the details of this, I want us to consider the potential of having the EMA here, the potential of the UK leaving and the effect this might have on drug pricing here. Drug pricing is something we obviously struggle with. It has an EU flavour when we talk about the reference pricing across the basket of 14 countries and so on.

There are two sides to implications for medical professionals. There is certainly an unhealthy exodus of medical professionals from Ireland at the moment, not just to the UK but across the English-speaking world in particular. That is a different day's work. There has traditionally been a very healthy sharing of medical professionals between Ireland and the UK. All the way through the training cycle, for example, our higher surgical training schemes are very much co-governed between the UK and Irish colleges. Many of our specialists spend some time on fellowship training in the UK. I can think, for example, of one patient in particular who attends us at present with a complex immune disease. Through contact with one of our own trainees who is now a consultant in one of the London hospitals, we were able to gain advice and that patient is now going to seek a very considered and planned consultation in London. The hope is that that trainee will eventually come back to take up a post and bring those skills back to Ireland with her. It is a very healthy exchange.

Given the tightness of training, one could paint a possible scenario that if the UK loses many of its other EU graduates, its French and German graduates for example, that it might try to fill that gap with Irish graduates. There is potentially a downside to the number of doctors suggesting that they might leave the UK.

One thing that we have been good at within the medical profession, both here and with our colleagues in the BMA, is really seeing the value of the larger European project. We are very well acquainted with each other through organisations like the European Union of Medical Specialists and the approach that organisations like that take to trying to improve the standardisation of postgraduate qualifications across Europe. That side of our work and engagement also needs to be protected through the course of Brexit.

Chairman

I thank Professor Duffy and all six witnesses for coming here this afternoon and for sharing with us a wealth of knowledge. We appreciate that, as well as their detailed responses to the questions posed by all three of us. We will now suspend the meeting briefly to change around the witnesses.

The select committee suspended at 12.43 p.m. and resumed at 12.46 p.m.