Deirdre Heenan critiques north/south health cooperation

Cross-border health cooperation ‘natural’ and ‘logical’

With few exceptions, cross-border health collaboration has been “minimalist and often project specific”, says Ulster University’s Deirdre Heenan, who argues that Covid-19 cooperation has not extended beyond “window dressing”.

From the earliest days of Covid-19 in Ireland, the absence of an all-island approach to dealing with this global emergency has been identified as a critical issue. We share a single island, are one epidemiological unit, and therefore cross border cooperation is not only natural, it’s logical.

Throughout the last year, it has been asserted ad nauseam that ‘this virus doesn’t respect borders’ and ‘the disease does not discriminate’, but has this led to significant policy action? Despite the broad acceptance that thinking in terms of narrow political allegiances or identities would only prolong this crisis and deepen the impact on every community, to date collaboration has been extremely limited.

Both governments have continued to plough their own furrow with little more than lip service paid to working collectively to fight this common scourge.

In March 2020, former First Minister Arlene Foster slammed the Taoiseach for lack of cooperation with Stormont over Coronavirus. She claimed that he did not brief the Northern Executive before announcing school closures and Belfast officials learnt of the new regulations through the media. The Irish Government pointed the finger of blame at the Executive, suggesting some were more interested in slavishly replicating Westminster policy, rather than developing a bespoke all-island response.

In April 2020, the signing of a memorandum of understanding (MoU) between the North and the South was broadly welcomed and viewed as a significant step in the right direction. In the face of this existential threat, it appeared that constitutional politics would rightly play second fiddle to public health considerations. The MoU acknowledged a compelling case for strong cooperation, including information-sharing and, where appropriate, a common approach, but at best it has made a marginal difference.

Practically, it has translated to regular Zoom calls between the Chief Medical Officers and some sharing of data. Window dressing and a far cry from the integrated, single-epidemiological coherent response to Foot and Mouth Disease (affecting livestock). Substantial differences in regulations, restrictions, data analysis and messaging pose practical challenges, cause confusion and are completely illogical on an island the size of Ireland.

The debate on the divergent responses to Coronavirus, coupled with the spectre of a border poll has pushed comparisons between the two healthcare systems into the spotlight. Prevailing wisdom in the North suggests that the health and social care system here is superior to the South’s HSE, but the reality is much more layered and complex. The North South Ministerial Council (NSMC) established under the Good Friday Agreement agreed six formal areas of cooperation, for which common policies and approaches are agreed but implemented separately in each jurisdiction, including in health and accidents and planning for major Waiting lists are currently 100 times that of England and this is a useful deflection. The regular and repeated calls for further collaboration and cooperation have not been accompanied by any detailed plans, cost-benefit analysis, feasibility studies or robust data to support an all-island approach.

Significantly though, the ability to make robust comparisons about health outcomes across the island is fraught with difficulties. Providing healthcare services commands one of the largest allocations of public funding on both sides of the Irish border and there are persistent concerns over the efficiency and effectiveness of these systems. Theoretically, closer cooperation could deliver economies of scale, value for money, opportunities for clinical specialisation and facilitate the sharing of knowledge. Over the past two decades health has been identified as a key area for increased cross-border working.

To date though, with the notable exceptions of the All-Island Congenital Heart Disease Network and the North West Cancer Centre at Altnagelvin, the approach has been minimalist and often project specific. Joint EU membership enabled cross-border healthcare activity in Ireland. Co-operation and Working Together (CAWT) was established in 1992, its mission ‘to improve the health and wellbeing of the border populations by working across boundaries and jurisdictions’. Through this vehicle significant work has been done to

“Both governments have continued to plough their own furrow with little more than lip service paid to working collectively to fight this common scourge.”

“The regular and repeated calls for further collaboration and cooperation have not been accompanied by any detailed plans, cost-benefit analysis, feasibility studies or robust data to support an all-island approach.”

emergencies. In response to the health emergency, the 24th plenary meeting NSMC was held in July 2020, the first since before the collapse of Stormont power-sharing in 2016. It gave a commitment to do ‘everything possible’ in coordination and collaboration to tackle the virus. It was agreed that an early meeting of the health sectoral group would be convened to review responses to the pandemic. At its meeting on 2 October, 2020, the sectoral group agreed to review its existing health work programme. No time frame nor objectives were agreed for this review.

The Health Minister is legally required to provide a statement to the Assembly on this meeting, to update on progress and allow for scrutiny. To date no statement has been presented, nor is one scheduled in the Assembly business timetable. If this is how a priority is treated, one wonders how the Government treats things that it doesn’t

enhance cross-border collaboration in health service delivery. Indisputable benefits have been achieved, providing access to services for communities within the border region, largely on a south-tonorth basis. However, in most instances in these initiatives funding has been timelimited, and services have not been mainstreamed. view as important.

Recently, the deputy First Minister, Michelle O’Neill, suggested that ramping up cross-border health provision could help to reduce Northern Ireland’s “dire” waiting lists. Whilst there can be no dispute that they are dire, this is empty rhetoric. Meaningful change in the all-island health agenda will not happen without a major policy imperative. There is an absence of any agreed strategic framework for health and social care systems to underpin cross-border cooperation, a situation exacerbated by the apparent lack of political will, north and south, to commit to all-island cooperation on an agreed plan of work.

Currently, there is a complete lack of momentum in this policy area. The pandemic has raised difficult questions about the extent to which both governments have lived up to commitments to developing cooperation across the island.

The new €500 million Shared Island Unit provides a unique opportunity to address the long-standing issues around cooperation in health and reflect on the Covid-19 response. A comprehensive programme of research and development could provide the evidence to identify interventions that would be to the ultimate benefit of all of the citizens on this island.

Given the similar social, economic and political pressures faced by both health care systems coupled with a pandemic that has steamrolled the country, it is an opportunity that we can ill afford to miss.

Deirdre Heenan is a Professor of Social Policy at Ulster University and Senior Associate at London’s Nuffield Trust.

Health research at the forefront of Ireland’s response to Covid-19

Ever since the coronavirus pandemic arrived on our shores over a year ago, the health research community has been at the vanguard of combating this crisis — whether working to find treatments and vaccines, alleviate the toll on our healthcare system, or address the broader societal challenges of living with the virus. For the Health Research Board (HRB), supporting Ireland’s response to the pandemic quickly became a top priority, writes Mairéad O’Driscoll, Chief Executive at the HRB.

Our team has been active on multiple fronts to enable leading-edge Irish research on Covid-19, deliver up-to-theminute evidence to inform decisionmaking, and shape a responsive research environment that can rapidly adapt to new challenges.

Pivoting funding for a rapid response

As the lead funding agency for health research in Ireland, the HRB has been driving the Irish research response to the pandemic since early 2020. Worldclass funding approaches embedded over decades meant we were in a position to pivot quickly and address the challenges of Covid-19. In March 2020, we launched a rapid response call in collaboration with Science Foundation Ireland (SFI) and the Irish Research Council (IRC) for research proposals to tackle the Covid-19 crisis in Ireland.

The HRB has invested in a total of 36 projects at a cost of approximately €5.5 million over the period between 2020 and 2022 to tackle the crisis from a wide range of angles. In addition to research that will benefit the health and wellbeing of patients, families, healthcare workers and the healthcare system, many of the projects investigate long-term health and societal aspects of Covid-19, such as mental health or patient risk factors. Such long-term solutions will be crucial as we continue to live with the virus and begin to re-open society.

Leveraging our clinical research infrastructure for Covid-19 trials

A resource that has proved invaluable in our response to Covid-19 has been the clinical research infrastructure supported by the HRB over many years, with an investment of over €160 million since 2007. This allowed us to quickly mobilise support for Ireland’s involvement in two global clinical trials of potential treatments for Covid-19. In April 2020, we supported the launch of the REMAPCOVID trial under the EU REMAP-CAP platform, which is testing interventions for Covid-19 in critically ill patients in Irish hospitals and sharing findings internationally. And in collaboration with the Department of Health and health research partners, the HRB facilitated Ireland’s participation in the World Health Organisation’s (WHO) Solidarity trial, the largest trial to date of treatments repurposed for use in the pandemic. Both REMAP and Solidarity have already produced valuable findings on the effectiveness of interventions for patients’ recovery and survival — findings which are now informing treatment of Covid-19 around the world.

Upholding robust ethical standards in times of crisis

Throughout this response to the pandemic, ethical considerations continue to take highest priority for Irish researchers. Reflecting our commitment to strengthen the national research ethics system in Ireland, the HRB supported the establishment of the first National Research Ethics Committee (NREC) at the request of the Minister for

Health, to provide rapid review of the ethics underpinning Covid-19 research projects. The Committee was supported by the National Office for Research Ethics Committees, a recently established independent unit in the HRB. From April to August 2020, NREC Covid-19 reviewed 93 applications from 61 institutions across 20 counties — accelerating the ethical approval of urgent studies around Covid-19.

Delivering the right evidence at the right time

In addition to addressing the crisis through research funding and infrastructure investment, the HRB has also contributed as a provider of trusted evidence in support of policymaking. Since the onset of the pandemic, government and public health leaders have sought rapid, scientifically sound information to guide their actions in an ever-changing environment. The teams at our HRB Evidence Centre, the National Drugs Library and Evidence Synthesis Ireland have answered this call by supporting the generation, updating and knowledge translation of evidence briefs, rapid reviews, systematic reviews, and WHO guidelines for the Irish Government. Our evidence products have helped inform decision-making as the pandemic has unfolded, delivering data in response to requests from the Department of Health within 24–48 hours.

Driving broader advances in health research

The pandemic has also proved a catalyst to drive forward advances in the Irish health research environment that can have a lasting impact. One such advance relates to the optimal use of health data for research — a key priority for the HRB. Since April 2020, a wealth of data on Covid-19 has been collected by the Health Service Executive (HSE), maintained within the Central Statistics Office (CSO) Covid-19 Data Research Hub. In collaboration with the Department of Health and the CSO, the HRB launched a mechanism in March 2021 to facilitate secure use of this data for research purposes. Ensuring stringent safeguards to protect patient and public rights, an independent Research Data Governance Board (RDGB) is responsible for reviewing researcher applications to access the data, with the HRB providing the Secretariat in support of this work. By enabling new data-driven research, this initiative can advance understanding of Covid-19, while informing future healthcare policy.

Another leap forward has been in the area of biobanking, with the HRB playing a central role in the establishment of a national Covid-19 biobank in collaboration with the Department of Health and other stakeholders. The aim is to create a prospective, disease-based biobank of Covid-19 samples and associated data, providing a resource for research studies to inform clinical care, vaccination, and booster strategies, and increasing the knowledge base for tackling future pandemics — while ensuring robust governance in line with best international practices, and full legal and ethical compliance. Biobanks and biobanking research play an increasingly important role in healthcare research and delivery as health systems become more patient-centred, and medicine becomes more personalised. This Covid-19 Biobank is a critical first step in supporting biorepository studies and data linkages as set out in the Resilience and Recovery 2020–2021 Plan.

One of 36 projects funded by the HRB and IRC under the National Rapid Response Research and Innovation call.

Providing trusted information

At a time when public trust in health research is more essential than ever, tackling Covid-19 misinformation has also been a top priority. In March 2020, the HRB supported the establishment of iHealthFacts, an online resource led by NUIG that enables the public to easily check the reliability of health claims. And with public trust crucial to the successful rollout of Covid-19 vaccines in the coming months, we have partnered with the Royal Irish Academy on ‘Vaccine Questions’, a series of podcasts featuring experts and scientists from around Ireland — putting listener questions to the expert guests to provide a reliable source of information on vaccines.

Investing in our future

This response to the Covid-19 crisis has served to reinforce our firm conviction at the HRB that funding for health research is not a cost, but an investment — an investment in our future as a society here in Ireland. The pandemic has been a stark reminder of how vital research is to improve treatments, support our healthcare system and inform decision making. And we have clearly seen how a well-functioning health and research system is essential to the functioning of our economy more broadly. In short, the quality of our health research system will remain essential for the wellbeing of our society, today and in the future.

“A resource that has proved invaluable in our response to Covid-19 has been the clinical research infrastructure supported by the HRB over many years, with an investment of over €160 million since 2007.”

For more information on the HRB’s response to Covid-19, please contact Gillian Markey, Communications Manager.

E: gmarkey@hrb.ie W: www.hrb.ie