The emergence of COVID-19 has illustrated the importance of cooperation and coordination on healthcare. From European Union health efforts conducted by the European Medicines Agency (EMA) and the European Centre for Disease Control (ECDC) to global health efforts conducted by the World Health Organisation (WHO), collaboration has proven to be an integral part of our pandemic response.
Cross-border cooperation and collaboration featured in Irish and European healthcare before the emergence of COVID-19. While cross-border health initiatives in Ireland have enabled Irish residents to be treated in Northern Ireland, cross-border health initiatives in the EU have enabled Irish citizens to be treated in other EU Member States.
The reciprocal nature of cross-border healthcare enables Northern Irish and EU residents to receive healthcare in Ireland. The UK’s decision to withdraw from the EU will have an impact an impact on cross-border healthcare.
What is cross-border healthcare?
In general terms, cross-border healthcare refers to circumstances in which a patient receives medical treatment in a country other than their own. Cross-border healthcare has benefits for patients including improved quality of healthcare, improved access to healthcare and the reduced expense of healthcare.
In an Irish context, cross-border healthcare refers primarily to North-South cross-border healthcare, however, Irish patients have additional access to cross-border healthcare through the EU.
In the former, an Irish resident receives treatment in Northern Ireland or vice versa; in the latter, an Irish resident receives medical treatment in a different EU Member State or vice versa. Various initiatives exist at a national level and at an EU-level in order to facilitate cross-border healthcare.
While the majority of cross-border healthcare initiatives will remain in place post-Brexit, Brexit will impact cross-border healthcare at a national and EU level.
EU and North-South Unit
Based in Leitrim, the HSE’s EU & North-South Unit works with healthcare providers in Ireland and Northern Ireland to deliver healthcare to patients in border areas and beyond. The Unit engages with agencies and departments on an all-island basis, arranging collaborative service agreements designed to facilitate the treatment of patients.
One example of a North-South partnership facilitated by the Unit is the radiotherapy service provided by the North West Cancer Centre at Altnagelvin Hospital in Derry. This arrangement provides patients North and South of the border with radiotherapy treatment.
Providing patients with prompt and direct access to healthcare, the cross-border care facilitated by the HSE’s EU & North-South Unit is critical for patients in border areas. In order to ensure that this care is uninterrupted, the EU & North-South Unit has prepared extensively for Brexit. Close cooperation with the Department of Health and close coordination with different branches of the HSE facilitate this.
The Cooperation and Working Together (CAWT) Partnership
Cooperation and Working Together (CAWT) is a partnership between healthcare services in Ireland and Northern Ireland. Established in 1992 by the Ballyconnell Agreement, CAWT facilitates cooperation between the Health Services Executive (HSE) in Ireland and the Southern and Western Social Care Trusts, the Health and Social Care Board (HSCB), and the Public Health Agency (PHA) in Northern Ireland.
CAWT is designed to install a cross-border dimension to healthcare by engaging with policymakers on cross-border developments, administering cross-border programmes, ensuring the cross-border mobility of patients and facilitating cross-border data sharing.
CAWT is a partnership focused on the holistic elements of cross-border healthcare, however, its primary purpose is to deliver EU funded programmes. These include the Power Primary Care and Older People Services programme which focuses on healthy ageing and the Mental Health Innovation Recovery ‘i-recovery’ programme which focuses on mental health.
CAWT is responsible for ensuring that these programmes are administered in accordance with the standards outlined in the Special EU Programmes Body (SEUPB).
EU funds for CAWT initiatives are provided by the EU’s Peace and Interreg programmes. The EU has committed to funding CAWT cross-border initiatives, ensuring that cross-border healthcare facilitated by CAWT will continue post-Brexit.
European Health Insurance Card (EHIC)
The European Health Insurance Card (EHIC) entitles EU citizens to medical treatment in the EU, the EEA and Switzerland if treatment is required while travelling. The EHIC covers pre-existing conditions in addition to accidents and illnesses that occur or develop during travel.
The purpose of the EHIC is to enable EU residents to travel without having to return home for medical treatment. To that end, the EHIC only applies to illnesses that emerge or develop during travel.
Patients interested in pursuing planned treatment in Member States other than their own are entitled to avail of other schemes such as Treatment Abroad Scheme (TAS) or the Cross Border Directive (CBD).
EU citizens are entitled to use the EHIC to access healthcare when travelling in the UK after Brexit. However, UK citizens travelling in the EU have to apply for a Global Health Insurance Card (GHIC).
Treatment Abroad Scheme (TAS)
Intended to provide patients with access to indispensable healthcare, the Treatment Abroad Scheme (TAS) enables EU residents to pursue treatment in the EU, EEA or Switzerland, in instances where treatment is inaccessible in their own country.
A treatment is considered inaccessible if it is unavailable in a patient’s own Member State, or if it is inaccessible in the time required i.e., if waiting lists in a patient’s own Member State prevent time-sensitive treatment.
In order to access healthcare abroad through the TAS, patients require an application form and a referral letter from a consultant. The referral letter will have to explain why the treatment is medically required and will have to provide evidence of the patient’s condition. Applicants approved by the HSE will receive an approval letter.
The TAS remains in place post-Brexit and Irish patients are able to access UK healthcare through the TAS.
Cross Border Directive (CBD)
Introduced in 2011, the Cross Border Directive (CBD) enables EU and EEA residents to access healthcare in EU Member States and in the European Economic Area (EEA). Designed to facilitate accessible and affordable healthcare treatment, the Directive affords patients the ability to bypass waiting lists in their own Member State by pursuing treatment in other Member States.
The Directive entitles patients to reimbursement for procedures in accordance with the legislation. Patients are reimbursed either the cost of the treatment in the Member State in which they were treated or the cost of the treatment in their own Member State, this depends on which is less expensive.
In contrast to the Treatment Abroad Scheme (TAS), the Directive only covers procedures that are publicly funded and nationally available. In order to access healthcare abroad through the CBD, patients require a referral letter from a GP or consultant. Patients are entitled to access healthcare through the CBD at any time in the treatment process.
On 1 January 2021, the CBD ceased to apply to the UK. Consequently, Irish patients are unable to access UK healthcare through the CBD, however, the HSE has agreed to transitional arrangements for patients that are already in the process of receiving healthcare through the CBD.
An alternative scheme termed the Northern Ireland Planned Healthcare Scheme (NIPHS) is in the process of being introduced.
The Northern Ireland Planned Healthcare Scheme (NIPHS)
Approved by the Government in December and operating on an ‘administrative basis’, the Northern Ireland Planned Healthcare Scheme (NIPHS) is intended to provide patients in Ireland with access to healthcare in Northern Ireland. Effectively a replacement for the Cross Border Directive (CBD) and the Treatment Abroad Scheme (TAS) the NIPHS operates on identical parameters to the CBD. The NIPHS entitles patients to reimbursement for procedures that are publicly funded and nationally available.
Supply of Medicine
Medical imports and exports are proceeding post-Brexit. According to the HSE, the supply of medicines to Ireland is expected to proceed with few disruptions. In the event that there are disruptions, the HSE has stated that it is well prepared.
A recent decision by the European Commission is expected to facilitate the importation of medicines from the UK post-Brexit. Due to the historical dependence of Ireland, Northern Ireland, Cyprus and Malta on the UK for the supply of medicines, the Commission has allowed for an additional period of one year – from January 2021 to December 2021 – for the UK to comply with the Union’s pharmaceutical acquis. This decision was communicated by a Commission Notice on 25 January 2021. Northern Ireland will remain under the EU’s regulatory regime for medicines.
Recognition of Prescriptions
The Department of Health has confirmed that prescriptions written in the UK by registered medical practitioners, registered dentists and registered nurse prescribers will be recognised in Ireland. Prescriptions written in the UK will have to conform to the legal requirements in place for prescriptions issued in other EU Member States: Regulation on this was introduced on 1 January 2021.
Where We Stand
The island of Ireland has considerable cross-border health infrastructure, from individual agreements to administrative and organisational partnerships. This will remain the case post-Brexit, however, certain pathways to treatment will change. Whereas EU initiatives including the Cross Border Directive (CRD) formerly provided a pathway to treatment, Irish patients will have to rely instead on all-island pathways to treatment, particularly on the Northern Ireland Planned Healthcare Scheme (NIPHS).