Written Evidence submitted by the British Medical Association for the Northern Ireland Affairs Committee’s inquiry into the future of the land border with the Republic of Ireland (BDR0031)

The British Medical Association (BMA) is a voluntary professional association and independent trade union, representing doctors and medical students from all branches of medicine across the UK and supporting them to deliver the highest standards of patient care. The BMA is committed to safeguarding the future of the profession and the patients we serve and it is essential we are consulted and involved in consultations to inform negotiations to leave the European Union (EU) which would affect the medical profession and patients.

The issues facing the medical, academic and public health workforce ahead of the UK’s withdrawal from the EU are considerable but have the potential to be felt even more profoundly in Northern Ireland given the unique situation of sharing a land border with the Republic of Ireland. The existing open border arrangements, since the introduction of the Common Travel Area in 1922, provide a number of benefits for patients, health services and health professionals, which risk being lost if restrictions are introduced following the UK’s withdrawal from the EU.

Executive summary

• The existing open border arrangements, alongside the expansion in the provision of all island healthcare, provide a number of benefits for patients, including access to both specialist medical services and to highly trained clinicians. This access risks being lost if border restrictions are introduced following the UK’s withdrawal from the EU.
• Cross border health services and patient access to healthcare, including cooperation of emergency services and other organisations in response to major emergencies, must be not impeded following Brexit.
• The government must ensure that doctors in Northern Ireland and the Republic of Ireland maintain the ability to move freely between both jurisdictions to be able to safeguard the sustainability of vital health services in both countries.
• In order to sustain the delivery of high quality all island services, it is vital that reciprocal arrangements, involving the transferability and recognition of qualifications for doctors, along with measures to ensure patient safety, are maintained once the UK leaves the EU.
• The government should seek to put in place clear arrangements which will be key to attracting and retaining highly skilled medical professionals in Northern Ireland.

What benefits currently derive from the existing open border arrangements?

All island healthcare

1. Evidence from Co-operation and Working Together (CAWT)[1] to the Lords Select Committee on the European Union revealed that cross-border cooperation with regards to healthcare has increased in recent years. Figures show that between 2003 and 2015, over €40 million was invested in cross-border health and social care initiatives via CAWT, with additional project applications amounting to €53 million submitted in relation to acute hospital services, prevention and early intervention, tackling health inequalities and other services.

2. Health services in Northern Ireland and the Republic of Ireland working separately often do not have sufficient demand to provide cost effective, highly specialist medical services.  The only viable way to deliver such specialist services to patients, such as the paediatric cardiology service, on the island of Ireland is to deliver these jointly; consequently, the last two decades have seen a significant expansion in the provision of all island healthcare. This has also meant that both Northern Ireland and the Republic of Ireland can retain access to highly trained clinicians who would otherwise not have the demand for a service to warrant their full time expertise.

3. For example, patients on both sides of the border benefit from the provision of out-of-hour GP services in Castleblayney, Co. Monaghan and Inishowen, Co. Donegal, as well as shared dermatology clinics at four sites along the border, and ENT Services at Monaghan Hospital and Northern Ireland’s Daisy Hill and Craigavon hospitals. Cross border collaboration has enabled ENT waiting lists in the Health Service Executive Dublin North East area to be significantly reduced by facilitating ENT consultants from Northern Ireland’s Southern Trust to practise in Monaghan Hospital[2].

4. The all-island paediatric cardiology service based at Our Lady's Children's Hospital, Dublin, enables children from Northern Ireland and the Republic of Ireland to receive treatment without having to undertake lengthy journeys or to travel to England to receive treatment[3]. The new Radiotherapy Unit at Altnagelvin Hospital provides access to radiotherapy services to over 500,000 cancer patients in both Northern Ireland and the Republic of Ireland. The creation of this service has meant that patients from Donegal in the Irish Republic no longer have to travel to Galway or Dublin for treatment[4]. The success of all these services is testament to what can be achieved with effective cross border co-operation.[5]

5. The Lords European Union Committee report on Brexit: UK-Irish relations concluded:

‘The increased and successful provision of cross-border healthcare is a demonstrable success story of effective cross-border cooperation. The launch of such projects has largely been dependent on the provision of EU funds, and it is vital that these and future projects are not placed in jeopardy by Brexit. Authorities on both sides of the border need to give assurances that these services will be funded in the future, that any practical issues arising from Brexit (such as the cross-border recognition of qualifications) are managed, and that formal and informal cross-border communication continues. It would be a tragedy if such cooperation, which improves peoples’ lives, were to wither on the vine’[6].

The BMA agrees with this assessment.

Free movement of UK and Irish health professionals across the land border

6. We welcome statements made by the UK government in the White Paper[7] and elsewhere regarding their desire to maintain the Common Travel Area thereby protecting the ability of UK and Irish nationals to move and work freely between the UK and the Republic of Ireland under the existing arrangements following the UK’s withdrawal from the EU. Should maintenance of the CTA conflict with EU law once the UK leaves the EU, we call on the government to work urgently with both the EU and Irish government to develop legally viable solutions which will protect the longstanding rights of UK and Irish nationals on the island of Ireland, to travel, work and live on either side of the border. We urge the Government to confirm that the rights of Irish citizens under domestic law will be maintained, whatever the outcome of the Brexit negotiations.

7. The existing open border arrangements enable medical professionals based on both sides of the border to currently travel freely to provide healthcare to their patients. This needs to continue both for the benefit of patients and for the services on which they so heavily rely.  However, it is worth noting that if, after Brexit, only the common travel area rules apply, then only UK and Irish nationals will remain protected by this freedom.

8. This would mean that separate arrangements may need to be put in place for EU nationals. The BMA is calling for EU nationals already in the UK to be given the right to remain, along with their family members, following the UK’s withdrawal from the EU. If the right to remain is granted, these EU nationals would retain the right to work and live in both the UK and RoI – however, this will require these individuals to have some form of documentation which would prove they have right to reside as well as protecting their ability to move freely between the UK and RoI.

Transferability and recognition of qualifications

9. There has been a long history on the island of Ireland for doctors from Northern Ireland to study in the Republic of Ireland and vice versa, and this trend continues to this day. There are complex cultural and political factors at work which necessitate this arrangement of transferability and recognition of qualifications continues.

10. Data from the GMC on licensed EEA graduates by country reveals Northern Ireland has a relatively high reliance on EEA graduates (8.8% of registered doctors)[8]. GMC data on EEA graduates by country of qualification and area of practice shows that the highest numbers of licensed doctors from within the EEA graduate in Ireland, with 3,196 doctors with a UK licence graduating from Ireland[9]. In contrast to the other nations of the UK, nearly three quarters of the EEA graduates working in Northern Ireland obtained their primary medical qualification in a single EU country – the Republic of Ireland.  A high proportion of these doctors are likely UK citizens from Northern Ireland who went to medical school in the Republic of Ireland.

11. It is of utmost importance that in order to sustain the delivery of high quality all island services this mutual recognition of medical qualifications between Northern Ireland and the Republic of Ireland continues. Concerns about indemnity for staff working in separately regulated jurisdictions after Brexit takes effect, and the implications for the flexible workforce, highlight the need to engage as early as possible with both professional regulators and medical defence organisations to raise the importance of maintaining existing frameworks.

Wider workforce challenges

12. There is a risk that the combination of uncertainty around Brexit, vacancy rates, and the recommendation in the Doctors’ and Dentists’ Review Body (DDRB) on doctors’ and dentists’ pay in the UK to only recommend an uplift in line with the public sector pay policy, which is well below comparable wage inflation in the wider economy[10] will further worsen the morale, recruitment and retention of medical staff in Northern Ireland. This combination of factors may exacerbate the existing challenges facing medical workforce in Northern Ireland which have been well documented. 

12 April 2017