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Performative nationalism among issues blocking needed cross-Border co-operation on health

Newton Emerson: Political squeamishness over need to rationalise hospitals on either side of the Border

A report last Friday from the Royal College of Surgeons in Ireland (RCSI) has proposed setting up surgical “networks”, each serving a set geographical area, so that emergency surgery can be centralised in fewer, larger hospitals. This would address the problem of recruiting and retaining staff and maintaining a consistent, safe service. Assessment units would be set up in every local hospital to ensure patients were sent swiftly to the right place.

The report could have been written about an argument convulsing Enniskillen, where emergency surgery is being moved 50 miles away to Derry. The Western Health Trust, the public body providing healthcare for the western half of Northern Ireland, says it is impossible to recruit surgeons to Enniskillen’s hospital. A vocal campaign group accuses the trust of not trying hard enough.

For a Border county, there is a strange indifference to identical issues in the Republic. Cavan’s general hospital lost emergency surgery 20 years ago because staff could not be recruited and retained. Even the Western Trust seems confused. Last October it said some patients might be treated in Sligo, also 50 miles away. But in December it said this would not happen as Sligo faces the same recruitment constraint.

Emergency surgery is not “accident and emergency” surgery but treatment that falls between trauma and elective care. Roughly speaking, it is surgery that can wait a few days but not a few weeks.


Losing emergency surgery does not mean a hospital loses its accident and emergency unit. However, ambulances with trauma cases will start bypassing it and other services may become unsustainable, so its loss tends to be seen as a slippery slope.

RCSI proposed that networks could sustain emergency surgery at smaller hospitals, although on an office hours rather than a 24-hour basis.

Campaigners in Enniskillen have asked the Western Trust to try something similar but the trust says rostering surgeons between Derry and Enniskillen is impractical.

Could a surgical network cover a cross-Border area? While the RCSI report does not say, it would be unfair to criticise the omission. RCSI engages regularly with its counterparts in Northern Ireland and surgeons are not responsible for running the health service North or South.

For those who are responsible, co-operation is rarely more than a platitude. A 1992 agreement on cross-Border collaboration has had limited success, mainly on granting patients access to each other’s facilities.

There are two major stand-alone projects: Derry provides cancer services to Donegal and all children’s heart surgery for Northern Ireland is performed in Dublin. The Taoiseach’s shared island unit has funded cross-Border medical research, including by RCIS.

That is the sum total of partnership after 40 years of supposed encouragement.

Constitutional squeamishness does not explain the reticence – all-Ireland children’s heart surgery was arranged by DUP former health minister Edwin Poots.

The real squeamishness is over rationalising any local facility. SDLP and Sinn Féin representatives will demand cross-Border co-operation to save services in Newry, for example. Ask those representatives if that means moving services from Dundalk, or sending northern patients to Drogheda, and they will have no answer.

This is performative nationalism as a way to pretend nothing must be done.

Although rationalising hospitals is a challenge for politicians everywhere, Northern Ireland’s mandatory coalition seems particularly unable to take locally unpopular decisions, even when Stormont is operating.

Decades of inaction have finally caused a crisis so undeniable that healthcare in the North is experiencing “reform through collapse”, as Ulster University professor Deirdre Heenan has termed it.

The factors driving this collapse, like population ageing and medical advances requiring specialisation, also apply everywhere. The Republic is better able to work around the resulting recruitment problems and loss of local services because its health system is larger. But it will run up against the same economies of scale soon enough. The Government’s planned new trauma system has a glaring hole across Cavan and Monaghan, where ambulance times will be over an hour. Could Enniskillen and Newry help plug that gap?

Until recruitment problems are addressed, there is a danger that cross-Border co-operation would become hostile competition for the same limited pool of staff. A useful project for the shared island unit would be lowering professional and administrative barriers to working across both systems. A larger project would be increasing medical training places throughout Ireland, perhaps by part-funding the new medical school in Derry.

While the public systems ignore each other, private healthcare is booming on an all-Ireland basis. Patients from North and South are crossing the Border to avoid waiting lists, either at their own expense or through public programmes to access private sector capacity, such as the HSE’s Northern Ireland Planned Healthcare Scheme.

As private healthcare grows, and bids for more staff, the recruitment problem in the public sector can only become worse.