On behalf of the committee, I welcome Professor Seamus McGuinness, research professor at the Economic and Social Research Institute, and his colleague Dr. Sheelah Connolly, associate research professor. We look forward to their engagement with the committee and the opportunity to discuss their research on differences in health outcomes between the health systems in Northern Ireland and the Republic of Ireland. The theme of health on the island of Ireland has been the primary focus for this committee since its formation in May. We have been continuing positive engagement with the shared island unit in the Department of the Taoiseach.

I will invite Professor McGuinness and Dr. Connolly to make opening statements. These will be followed by questions from members of the committee. Each member has a five- to seven-minute slot to ask questions and for the witnesses to respond.

I remind members of the constitutional requirement that to participate in public meetings, members must be physically present within the confines of the Leinster House complex. Members of the committee attending remotely must do so from within the precincts of Leinster House. This is due to the constitutional requirement that to participate in public meetings, members must be physically present within the confines of the place where Parliament has chosen to sit. In this regard, I ask members partaking via Microsoft Teams that, prior to making their contribution to the meeting, they confirm they are on the grounds of the Leinster House campus.

Members and witnesses are reminded of the long-standing parliamentary practice that they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable, or otherwise engage in speech that may be regarded as damaging to the good name of the person or entity.

Therefore, if their statements are potentially defamatory in relation to an identifiable person or entity, I will direct them to discontinue their remarks. It is imperative that they comply with any such direction.

As the witnesses will be aware, the committee will publish their opening statements on its website following the meeting.

MPs participating in this committee session from a jurisdiction outside the State are advised they should be mindful of their domestic law and how it may apply to their participation in these proceedings.

I invite Professor McGuinness and Dr. Connolly to make their opening statements.

I apologise in advance if this is a bit lengthy. I thank the Chair for the invitation to the ESRI to appear before the committee and for the opportunity to discuss ESRI work comparing the economies of Ireland and Northern Ireland. I am Professor Seamus McGuinness and I am joined by my colleague Professor Sheelah Connolly.

Together we have been involved in producing comparative research on differences on health outcomes and the health systems in Northern Ireland and the Republic of Ireland. The majority of our research in this area has been undertaken as part of the joint research programme between the ESRI and the shared island unit in the Department of the Taoiseach. Relative to other comparative studies undertaken as part of this joint research programme, research on health status and the relative performance of both health systems has proven particularly problematic as a result of very limited available comparable data. We will briefly summarise some of our key findings on the relative performance of the healthcare systems to date before providing further details on the nature of some of the data issues constraining comparative research on health systems and outcomes in Northern Ireland and the Republic of Ireland.

The analysis of the primary care systems of Ireland and Northern Ireland was published in March 2022 and represents our most substantive research project to date, comparing the health systems of the Republic of Ireland and Northern Ireland. The report notes that a key distinction between the healthcare systems is the existence of a universal healthcare system in Northern Ireland, whereby all resident individuals are entitled to a wide range of health and social care services that are almost entirely free at the point of use. Conversely, in the Republic of Ireland, a majority of the population pay out of pocket for a range of healthcare services, including general practitioner and other primary care services.

In the Republic of Ireland, there is much greater private provision of healthcare services and a larger proportion of the population is covered by private health insurance. Despite these differences, both systems are facing similar challenges, including increasing demand for healthcare services, increasing expenditure and workforce shortages. The 2022 report attempted to compare a range of indicators across the two jurisdictions, including GP provision and utilisation, healthcare expenditures, unmet healthcare needs, the use of preventive services, avoidable hospitalisations and waiting times for hospital-based services.

Some of the key findings from this research are as follows. The number of GPs per capita was found to be similar across the jurisdictions. However, no comparable data were available on the number of whole-time equivalent GPs. The available evidence leads to no clear conclusions regarding whether GP utilisation is higher in either jurisdiction. The study uncovered higher levels of unmet healthcare needs due to affordability issues in the Republic of Ireland relative to Northern Ireland. However, the most common reason for unmet healthcare needs in both systems relates to long waits to access care. In terms of avoidable hospitalisations, neither system consistently performed better than the other. For example, the hospitalisation rate related to influenza and pneumonia was 30% higher in Northern Ireland, while the hospitalisation rate for chronic obstructive pulmonary disease, COPD, was found to be 18% higher in the Republic of Ireland.

The authors raise a number of policy-related conclusions on the basis of the 2022 study. While affordability constraints contribute to higher levels of unmet healthcare needs in the Republic of Ireland, the implementation of the Sláintecare reform proposals, which are aimed at ensuring that access to primary healthcare services in the Republic of Ireland is based on need rather than ability to pay, would mean a greater alignment between the healthcare systems of the Republic of Ireland and Northern Ireland.

A significant barrier to accessing healthcare in both jurisdictions relates to the long waiting times for hospital-based services. While there have been some reductions in waiting times in both jurisdictions since the Covid-19 pandemic, wait times for many hospital-based services remain high on both sides of the Border. Reducing these waiting times, in particular in a system of increasing demand, will require a multifaceted approach, with an emphasis on service delivery, workforce capacity and skill mix in both jurisdictions.

Turning to findings on health-related outcomes and expenditures from the 2025 comparative economic report, in our 2025 assessment of the Northern Ireland and Republic of Ireland economies, it was found that per capita Government expenditure on health in the Republic of Ireland exceeds the level of per capita expenditure in Northern Ireland. In this research, we calculated the per capita gross Government expenditure for 2022–23, adjusted for purchasing power parity, PPP, for the various components of Government expenditure. We found that health spending accounts for 26.3% of per capita Government expenditures in the Republic of Ireland compared to 17.3% in Northern Ireland. In nominal terms, per capita Government spending on health in 2022-23 was estimated at €4,739 in Northern Ireland, compared to €5,853 in the Republic of Ireland, a gap of 23.5% in per capita health spending favouring the Republic of Ireland.

The study also examined hospital inpatient and outpatient waiting lists per 1,000 of the population for both jurisdictions in 2024. For waits of between zero and six months, waiting times for inpatients and outpatients are similar. However, the proportion with very long waits was found to be much higher in Northern Ireland. For example, there was one person per 1,000 of the population on an inpatient waiting list for more than 18 months in the Republic of Ireland, compared to 20 persons per 1,000 of the population in Northern Ireland. In respect of outpatient waiting lists, the research found that there were ten persons per 1,000 of the population in the Republic of Ireland on a waiting list for more than 18 months, compared to 66 persons per 1,000 of the population in Northern Ireland. Combining inpatient and outpatient data, the research found that there were 86 persons per 1,000 of the population on a waiting list for more than 18 months in Northern Ireland, compared to 12 persons per 1,000 of the population in the Republic of Ireland.

The 2025 study calculated the number of hospital beds per 1,000 of the population in Northern Ireland and the Republic of Ireland between 2009 and 2022. While the rate of hospital bed provision was substantially higher in Northern Ireland in 2009, at 4.1 beds per 1,000 of the population compared to 2.8 per 1,000 of the population in the Republic of Ireland, this gap has gradually narrowed over time by virtue of per capita declines in provision in Northern Ireland. By 2022, the number of hospital beds per 1,000 of the population stood at 3.2 in Northern Ireland and 2.9 in the Republic of Ireland.

The 2025 study was also able to examine infant mortality rates per 1,000 live births in the Republic of Ireland, the UK and Northern Ireland over the period from 2012 to 2022. In 2012, infant mortality rates in Northern Ireland and the Republic of Ireland were broadly equivalent and below the UK average. However, the intervening period has seen infant mortality rates falling in both the Republic of Ireland and the UK as a whole, but rising in Northern Ireland. In 2021, infant mortality rates per 1,000 live births were 2.8 in the Republic of Ireland, 3.6 in the UK and 4.8 in Northern Ireland. The emergence of a substantial infant mortality rate gap between Northern Ireland and the Republic of Ireland over the period from 2009 to 2021 is an extremely worrying development.

Finally, life expectancy in both jurisdictions is an indicator that reflects the impact of multiple well-being determinants across a range of areas, including income levels, educational attainment but also access to health services, including preventive services. In 2000, the life expectancy of children aged under one in the Republic of Ireland was approximately one year lower than that in Northern Ireland. The rates converged around 2006, with life expectancies increasing more quickly in the Republic of Ireland relative to Northern Ireland thereafter. In 2021, life expectancy for children aged below one in Ireland was 82.4 years compared to 80.4 years in Northern Ireland, a gap of two years in favour of the Republic of Ireland.

To conclude, it is important to state from the outset that comparative research into health systems and outcomes in both jurisdictions is much less developed than other aspects of society, such as our work in education or the economy, due to a lack of comparable data. While the two respective administrations publish a range of health system indicators, differences in how the indicators are defined, collected and reported mean that accurate comparisons are often not possible.

Despite these challenges, our research allows us to draw some broad conclusions on how health and health systems compare. Both systems currently face similar challenges, including increasing demand for healthcare services arising from, in part, an ageing population, increasing expenditure and workforce shortages. While in the past health outcomes tended to be better in Northern Ireland relative to the Republic of Ireland, this has changed in recent years with the Republic of Ireland now performing better than Northern Ireland in infant mortality and overall life expectancy. Financial barriers to accessing healthcare are greater in the Republic of Ireland. However, access issues arising from long waits for public hospital services are an ongoing issue in both jurisdictions despite some improvements in recent years.

I thank the witnesses for attending today. We have some interesting, shocking and surprising data in front of us. People tend to think that a universal healthcare system may provide a better health system. That is not necessarily the case, especially given the statistics. The Republic fares very favourably in some areas in results like waiting lists, life expectancy and expenditure. Then again, people in the Republic are paying through the nose for their healthcare services which could have some bearing on those results.

Infant mortality rates are very worrying. Before digging into the issue, this is about data research. The presentations referred at the start and end to limited available comparable data. What are the main gaps that currently limit a robust all-Ireland health comparison?

When we carry out an analysis of Ireland or Northern Ireland, there are a couple of different sources of data. There is administrative data which the Government, Department of Health or HSE, for example, will produce. In Ireland, this data has been poor in the past, although there are more resources and better data now. Northern Ireland probably had better administrative data all along.

One of the big gaps is the way things are defined and reported, which often do not align in both jurisdictions. For example, waiting lists for hospital-based services in the Republic of Ireland might state targets are around 12 weeks and therefore it will publish data on the number of people waiting beyond 12 weeks or 16 weeks. In Northern Ireland, reflecting its targets and what is happening in its system, the data might refer to nine or 18 weeks. There are good reasons Northern Ireland does things differently but it makes it problematic to make comparisons.

There is a recognition of different data from different jurisdictions in health and other areas. That can be really useful for making comparisons across systems. Organisations like the OECD and Eurostat publish national level data, which we can use for research and to make comparisons. A lot of that data is at the UK level. The UK is dominated population-wise by England, and therefore the data may not be relevant for Northern Ireland. That is a real gap in the international data infrastructure. In Europe and Eurostat, there is some data at the Northern Ireland level, but again with Brexit that is potentially less relevant over time. They are some of the factors that contribute to this.

How reliable are the results? What can we do to make them better in the future?

When we started the report that was published in 2022, we had a long list of perhaps 30 indicators that we wanted to compare. We realised quite quickly that this would not be possible. The ones we have produced are those we think are generally comparable. There are some caveats around that. If we want to do better in the future, that will require a concerted effort. This will not happen by accident. The jurisdictions will continue to do what they do, which reflects their systems. A group or organisation needs to ask whether there is a minimum dataset we would be interested in and somebody needs to push or fund that or do whatever is needed to be done in order to get that up and running.

One of the improvements in recent years is that we have survey data and there has been an increase in the number of surveys that are potentially comparable across the jurisdictions. We have surveys on older and younger people, which are comparable.

That plugs some of the holes, but it does not give the kind of system-level indicators we might be interested in about the workforce and about the expenditure. That is something that will have to come from the administration.

Digging a little deeper, are there particular areas of care for perhaps elective procedures, diagnostics or mental health where cross-Border differences are most pronounced?

We did have an extensive opening statement but we are almost putting out all of the comparable data that we have. There have been some improvements in terms of Dr. Connolly's report in 2022. When we looked at 2025, we were able to dig a lot more into infant mortality. There has been improvements in the hospital inpatient and outpatient waiting lists. However, for a lot of the other aspects, we really do not have much information. Even in terms of GP utilisation we still do not know much about that and how they compare our particular types of service. All we are looking at mostly now are the outcomes of how the health system plays out. Actually, we are nowhere near the level of detail and the granular level of analysis needed to really understand the differences between the systems and how they are working to produce those outcomes, and we are unlikely to be without major changes in the data infrastructure and data collection procedures both sides of the Border and a more integrated approach to those.

The health outcomes metric is the most robust in that they are measured in a consistent manner across the jurisdictions and we are seeing that kind of change Professor McGuinness mentioned, where previously Northern Ireland was doing better but now that seems to have shifted in favour of the Republic.

Overall the life expectancy has increased, albeit slightly more in the Republic. I am worried though, because then we are seeing longer life expectancy and we understand why as there may be health issues, but the infant mortality rate really popped out at me, particularly in Northern Ireland. To what extent does this report allow us to assess intergenerational health impacts, particularly for children growing up in lower income households? Is there a correlation between that?

No, we would not be able to say very much on that in terms of intergenerational outcomes related to health. We have done a little bit in terms of educational outcomes where there is much better data. For example, we were able to say that, in Northern Ireland, young people are less likely to match or exceed their parent's educational attainments relative to the Republic of Ireland. In terms of intergenerational transmissions and those effects that work through, there is no research being done currently with our programme with the shared island unit. Again, everything we propose for our work with the Department of the Taoiseach is data-driven. We would not be in a position to produce really detailed analysis on those sort of intergenerational impacts of health differentials both side of the Border.

It might be possible into the future with those longitudinal datasets which focus on younger people and older people. We might be able to address some of those but, certainly the data is not available at the moment to dig down.

We are also concerned about population growth as well on both sides of the Border. How is this likely to exacerbate the problems in the future and the pressures on the healthcare system?

Population growth in the last number of years has been significantly higher in the Republic relative to the North but both are experiencing significant growth. On a separate programme of work we have recently produced projections out to 2040 about how the growing and ageing population will impact on demand. It is going to increase for all of the services we looked at. It differs depending on what service you are looking at in particular. There will probably be a minimum 20% increase by 2040, but if we are looking at those services that are really used by older people like hospital inpatient admissions, residential care, home supports and people coming into the home to look after people, there could be an increase of 50% to 60% by 2040. That is a relatively short period of time. That is a real challenge for the health systems on both sides of the Border but probably especially in the Republic because of the demographics.

I welcome the witnesses and thank them for the opening statement. I thank them for coming in this morning. What does this research tell us about where the co-operation under the Good Friday Agreement can add the most value in healthcare?

Earlier in the year, we published an overview of life on the island of Ireland, Sharing the Island: Economic and social challenges and opportunities: Evidence from an ESRI research programme. We tried to draw together everything that we had done as part of the research programme with the Department of the Taoiseach. We also looked at the issue of cross-Border co-operation, both under the bodies that are directly under the North-South Ministerial Council and the areas of co-operation related to health. With the exception of tourism, we came to the conclusion, and the general literature also suggested, that where there is co-operation, it tends to be project-based and not systematic.

This also relates to health. There is no systematic approach to delivering all-island healthcare. We looked at some good examples of co-operative practice that have emerged in recent years, for example, the provision of paediatric cardiology services in Crumlin hospital, the North West Cancer Centre and cross-Border coronary intervention services at Altnagelvin hospital. Again, these are very much project-based, but there is very little evidence of a systematic, joined-up, cross-Border approach.

We saw the costs of not having that approach during the pandemic, where differential rules were brought in on both sides of the Border. We recently published a paper in The

Economic and Social Review that looked at where infection rates were higher. We saw that there was a particular spike in Border areas, which were much higher than the rest of the country. This was actually in more affluent Border areas, where people perhaps had the capacity to go across the Border and exploit the differences in the rules. There were clear costs related to the infection rates from not having a more joined-up approach to health provision, particularly during the pandemic.

To characterise the situation, as I said, there is evidence of good practice in cross-Border co-operation on particular projects, but there is no systematic approach to attempting to move towards an all-island system of delivery.

I thank Professor McGuinness for the response. It is good to see that there is co-operation in some cases, which is welcome. Are there areas where data alignment, North and South, would improve policymaking?

As to where we would seek improvements, GP utilisation is one area.

The two systems are quite different, in particular for primary care and GPs. As I said, it is a universal system in Northern Ireland, so access to the GP is free at the point of use. In Ireland, as was mentioned, the majority of the population pay out of their pocket. One of the things we try to look at in the report is how that impacts the system. It is like a natural experiment. Without those fees, we would expect that certain things would consequently be better in Northern Ireland. The first thing is that we found it very difficult to do that because the data environment is poor, in particular for general practice. They are private providers, so we do not have a lot of publicly available data on that side of things. There is not great data in Northern Ireland either to allow us to make those comparisons.

What we did see is that just because it is free at the point of use, that is only half the story. Even if it is free, there can still be other barriers to access. What we are seeing in Northern Ireland in recent years is that, as demand is increasing, people are finding it increasingly difficult to get an appointment. Therefore, people are being given free GP care, but if they cannot get an appointment, that eligibility is not very helpful. There is probably a lesson there for the Irish situation. In increasing access to GP care by removing financial barriers, we need to ensure that the workforce is available to meet the additional demand. However, given the data availability, we were not able to dig too far into that issue.

We do not know how long people have to wait for GP appointments on both sides of the Border, but it is something we really want to know regarding the primary care aspect. There is also very strong anecdotal evidence that more and more people north of the Border are accessing private GP services.

With that type of information, we need to get the graphs to really understand the differences that are occurring and evolving between the two systems, particularly as the pressures continue to grow.

Therefore, more information is needed from both sides.

Yes, and that would open up the potential learning.

Does the research indicate whether the workforce shortages are a binding constraint in both systems? Dr. Connolly touched on it when she gave-----

We frequently hear that there are workforce issues. Certainly, in the North it seems to be an issue that has been going on for a number of years. In the Irish State, the health workforce on the public side has increased substantially in the last number of years. In particular areas of the country and in particular services, however, there is a shortage. That is a current issue and coming back to the previous point about how the demand will increase in coming years, this is raising the really significant question as to where these workers will come from on both sides of the Border as demand increases and as the population is ageing. The potential workforce in a relative position is decreasing as well. It is certainly an ongoing issue and I wonder if it is likely to be exacerbated in the future.

While the NHS is generally seen as being a single system, the performance of the health services in England, Scotland, Wales and Northern Ireland are very different. While we find that the per capita spending on healthcare is generally slightly higher in Northern Ireland when we shake it out of the national accounts, there are big differences across those four jurisdictions. Data was published recently by FactCheckNI and we cited it in previous research. It is for combined inpatient and outpatient waiting lists of more than 12 months, expressed per million of population. It is 140,000 in Northern Ireland compared with 70,000 in Scotland, 32,000 in Wales and 6,700 in England. That is a huge variation. The North is a massive outlier in that respect, despite the per capita funding being broadly equivalent across the four jurisdictions.

I welcome Professor McGuinness and Dr. Connolly. This is a very interesting discussion and it forms part of our overall discussion on what an all-island health service would look like. We are trying to avoid the slogans on the back of a bus, so it is good to answer as many questions as we can. I thank the witnesses for the work they have been doing, albeit with the constraints on the data.

Last week, Mike Nesbitt appeared before the committee as part of this discussion. He talked about the encompass system, the new technology system that is being used up there. Obviously, the systems in each of the jurisdictions need to be talking to each other. Do the witnesses have any knowledge of what is being done in that area? If creating a new system, would it make sense to look at it in an all-island context rather than as a single jurisdiction so that we will not be back here in five or ten years' time still saying we do not have the data infrastructure to enable us to answer the questions accurately?

I think that probably makes sense and the time to do it is now, before these systems get embedded. Even within Ireland, if we leave Northern Ireland out, we do not have one system. In the past, individual GPs might have had different systems. There is not that data infrastructure despite significantly increased funding in the last number of years and the move towards digitalisation. We do not have one system in Ireland across the board. We do not have a unique patient identifier to allow us to track patients from the GP to the hospital. Some of the hospitals use different systems. We are probably quite a bit away from having one system North and South given where we are currently in the South with the various systems.

Would Dr. Connolly recommend that we should have one system? I accept what she has said about how there are already some anomalies within the jurisdiction. The experts on cancer research and congenital heart disease who appeared before the committee said that we would never reach an optimum level of healthcare delivery without having an all-island approach.

Would the ESRI recommend that we have uniformity across the system?

Certainly, in regard to the type of work the ESRI is doing and the type of research we would try to do, if there was one system it would be much easier to do that.

Obviously, we are avoiding duplication and maximising economies of scale, so it always makes sense in an island situation. If we were designing a system, we would design it as a single entity rather than two separate systems, of course. In terms of the broader constitutional question, the need to plan is something we brought up in our work. People need to know what the health service will look like in the event of any Border poll ratifying unity. We pointed out what the options are, namely, to have two separate systems and align to the best system or to have it separate and start to redesign an integrated system, and the question as to how long that will take. That requires a lot of detail and a lot of work from clinical experts and statisticians. The economic implications of that need to be modelled. A huge amount of planning would be required in terms of the constitutional bit. People want to know, in particular, what their education, health, tax and social welfare systems will look like on the other side of a Border poll. That is all necessary for this going forward, for sure.

How could the macroeconomic model the ESRI developed with IBEC to answer some of the economic questions be applied to answer those questions in health as well, or is there a crossover?

There are limitations to macroeconomic models and they cannot deliver everything. What a macroeconomic model can do, at least for some policy changes, is it can look at them. Health is a much more difficult one, but we can think of changes around the education and training system and there are gaps there, for example, particularly within the post-secondary system. In that model, we could ask what will happen if there is convergence between the North and the South over a period. We could ask what the impacts of that would be in terms of productivity, how long it would take to see a productivity effect and how that would then feed into it, if we wanted to look at subvention and things like that. The macroeconomic model could be used potentially in that scenario to frame potential policy options and to point out the likely timeframe of adjustment. It is much more difficult to do that using health. It is not a component of the macro model, so that would be a more difficult one to model.

Could it be used in the measurement of the determinants of health?

In what sense?

In terms of levels of education, levels of poverty and all of those things that can add up to poor health outcomes.

In the sense that education would feed through to outcomes. We would need to have Adele Bergin here to talk explicitly about life expectancy. She is the macro expert. There are limitations to what that macro model can be used for in terms of the level of detail. It is important in providing a broad framework of the likely benefits of particular policy changes in major areas that affect, predominantly, the economy, but not so much health dynamics.

Where do we start with the infrastructure that is needed? Professor McGuinness mentioned it being driven by the two Administrations. Would he see that as the two Ministers for health, or the Taoiseach and the First Minister, or who would he see as being involved in us getting that infrastructure in place?

In terms of all-island infrastructure?

Yes, for health.

The primary area we might look to immediately would be the North-South ministerial bodies. Health is one of the six areas for co-operation, I suppose so that is where we would start. We did say that our earlier report of 2025 that basically, North-South co-operation has not matched expectations, particularly around what was envisaged in the Good Friday Agreement. It tends to be rather ad hoc right across all of the areas of co-operation, so there is much more benefit if there is a sustained approach across all of the six areas. If we look at the model of tourism, that has been a particular success of North-South co-operation.

Similar benefits would certainly be there to be gained in the areas of health and education.

Even before that, which is a medium- to long-term objective, a minimum dataset that was comparable across the jurisdictions would fill in some of the gaps we are finding difficult to fill in the context of what is happening within the system. It would probably be easier to achieve as a short-term objective before we move on to the infrastructure.

This is a bit time sensitive. I propose that we write to the Minister for Health about the encompass system in the North and recommend its use. I am conscious that it could be six more months before we complete our report. Before the committee makes its recommendations, an examination of that model could be carried out in order to see if we can look at what is involved on an all-island basis.

I thank Professor McGuinness and Dr. Connolly for the report. I found it really interesting. They have done a pretty good job at comparing metrics from data systems that we in the health services have always struggled with in the context of even comparing things across the various regions. They touched on that a bit when they were speaking about the position across the UK. In the North, we have the only integrated health and social care system that operates across the UK. That brings its own issues when it comes to investment, funding and why we have underinvestment in social care. We can see that play out.

I also listened to a programme on Sunday that Ms Lawless, the ESRI chief executive, appeared on. The report sets out most of the metrics very clearly and you can draw the conclusion the South is ahead. There is no doubt about that. I am not asking for others to draw this conclusion, but the conclusion I draw, as a nurse, and now as a politician, is the impact partition has had on the health of people in the North, particularly around the Border area where I am working at this point. On Sunday, Ms Lawless also made the point that maybe in some of its future work, the ESRI will look at a regionalised approach. I understand it is going to compile further annual reports. Are there particular areas within regions it would look at? If it was to do that, where would it start?

We probably all know why our infant mortality rates are higher in the North. It is to do with deprivation, poverty, poor housing and maternal health. Those are all things we have battled against within the profession as well. What areas would benefit from looking at them in a regionalised approach?

That is a difficult one. As Ms Cullen says, there are issues and there is a legacy of that in terms of what is happening in the North, particularly around the Border. We have a report coming out where we look at disability rates. We are finding out while the headline disability rates in both jurisdictions look similar, the rates of severe disability are higher in the North. There are also age differences that obtain. That is the type of thing we could look at. There is probably sufficient data to look at that on a regional level.

In terms of other metrics, our life expectancy data comes from the OECD. There is a regional database and there are some breakdowns you can give for some of these metrics. In terms of what we could look at, we could produce a wish list but we will have to be data driven here. As the data is produced and more of it is produced at a regional level, we will examine it. Until that happens, we are just looking to see what is out there and to exploit it as much as possible. Unfortunately, that is the position we are in. On issues you can look at around health using census data, we can look at disability rates and do a good level of detail on that because those two datasets are sitting there and are comparable.

When we look at the census data, however, there is not an awful lot more in it on the health side. As Dr. Connolly said, we are looking at the longitudinal datasets that are being produced on both sides of the Border. We are hoping for greater comparability there, but I am not sure there is a regional dimension even in those datasets. We are pretty limited in terms of what we can do at the moment without a major change to the data infrastructure.

Access issues would be really interesting to look at. Deprived areas and deprived individuals generally have a higher requirement for healthcare services. If we are thinking about GPs, sometimes they are less likely to set up or be located in deprived areas. There might be a similar issue in rural areas. There are fewer health professionals working in such areas. People in particular areas might have to travel further for hospital-based services. While access to healthcare services is just one issue in terms of the impact on health status, to get some of the data at a regional level would be really worthwhile also. I am not sure we are at the point where we would have it on a comparable basis between the Republic and the North at the moment.

We have really only been getting comparability in the past couple of years on some very basic broad-level indicators. The data infrastructure is the major problem.

We battled big time with it when we were setting up the paediatric cardiac surgery services on an all-Ireland basis. We had many sleepless nights over that. I remember sitting with Frank Casey and others trying to look at how we would collect comparable data, because it was so important. It can be done. The point is that we need to put our shoulders to the wheel to start to look at all-Ireland healthcare on a broader basis than just doing the odd project here or there. We owe it to the clinicians, to the people trying to deliver the service and to the people also.

I apologise to the witnesses for being late. I had another commitment. I am very glad to be here. The high levels of unmet healthcare needs and affordability constraints here in the Republic have been mentioned. It was suggested that Sláintecare reforms might address this. I apologise if this question has already been asked, but does the data available allow us to project where we might be in five years' time with Sláintecare?

The point we were making, and this question has not already been asked, is that the big distinction we heard about historically in a North-South context was that there was free GP care in the North while people in the South were paying out of pocket. This is a big issue. Sláintecare was moving towards this universal system and reducing these user charges. If it were implemented in full, it would reduce this potential difference between the two systems. There have been some improvements and some changes. A lot of the hospital-based charges have largely been abolished. There are some for emergency department admissions but inpatient charges for those who do not have a medical or GP visit card have been reduced.

The other big move is the increase in the number of people with a GP visit card. When it was introduced in 2023, the Department of Health stated that there would be somewhere between 400,000 and 500,000 people who would no longer pay for GP care. This is a substantial component that would bring the two systems closer together. The caveat is that uptake in respect of the GP visit card has been relatively slow. We looked at it six months ago when we were doing other work. The level of uptake was probably somewhere less than 150,000 out of a potential 450,000. It is about one quarter. The first step would be to ensure those who are eligible for it, where eligibility is already in place, are taking it up. People are entitled to it but for some reason they are not availing of it.

I have asked the following question at previous meetings. The witnesses might be in a unique position to answer it.

What struck me most about these reports were the findings on health inequalities between the two jurisdictions. This goes deeper than just North and South. Last week, the Minister of Health in the North told this committee about two areas in the North less than a mile apart. He said the healthy life expectancy between them varied by 14 years, which is phenomenal. This might not be something in the witnesses' areas of research, but I will throw the question out there anyway. How can we better understand the particular vulnerabilities and health needs of individuals and communities? In other sessions, we discussed the possibility of a health mapping exercise or of maybe creating an index similar to what Pobal has done to identify geographic disadvantages in health. Is there something the witnesses could share? Do they have an opinion on this? Maybe they do not.

We have tried to look at the extent of health inequalities across both jurisdictions using similar indicators to ensure we are measuring things comparably. We have not been able to with the way things are defined, even at a relatively simple level. We have done some work within Ireland looking at health inequalities. We published a report a couple of years ago looking at socioeconomic inequalities in health, which is what the Senator was alluding to. There is a big distinction, in that people from a higher socioeconomic group, however that is defined, are living longer.

We also looked at perinatal mortality, which is slightly different to infant mortality. One of the statistics we are seeing is that, in Ireland, there are particular groups. Socioeconomic status is important, but we are also finding that country of birth is important. People coming from African countries in particular are experiencing a very high perinatal mortality rate while other groups, such as people born in Ireland or elsewhere in Europe, had perinatal mortality rates decrease over time. For this group, though, it had not. It was largely comparable over a relatively long period.

Health and the health system comprise one factor that influences our health but we need to look much more broadly at deprivation, education and income. We also need to look at the health system and access to healthcare services and ensure all of those issues are addressed. That is tricky because it is not one Department. It is not just the Department of Health, which can only do so much. With things like the environment, all the different Departments are involved. It really requires a cross-Government approach, even within the Irish context, to try to deal with health inequalities. While health is improving at a population level, those inequalities still exist and there are some groups experiencing barriers to accessing healthcare and a whole range of other factors that negatively impact on health.

We measure levels of deprivation on both sides of the Border at a pretty small level. There is not a consistent approach. If you look at the HP deprivation index, for example, a lot of the deprivation measures that have been out there historically are largely driven by area-level unemployment. There is value in looking at a new approach and having a cross-Border approach in terms of collecting metrics at a small area level that feed into those inequalities. I am thinking about information around income levels, but also information on access to primary care services, access to preventative health services, educational attainment and all of the things we now know are important in terms of the differences in outcomes. It would be a valuable tool going forward to begin to map those and collect data on them consistently at a small area level right across the country.

The mapping idea really came across last week when the Minister was here. Fourteen years is an unbelievable difference in life expectancy between two areas a mile away from each other.

Disability rates also need to feed into that.

I thank the witnesses for coming in.

This is a fascinating conversation. A lot of the questions that I intended to ask have been addressed already.

In our experience of dealing with the issue of all-island healthcare, it has become abundantly clear over the past number of months that there is huge willingness across all sides, regardless of people's political ideologies, to co-operate on this. If we can get this right, the net result will be improved healthcare outcomes on both sides of the Border. When we look at issues like appropriate locations for centres of excellence, all of that has to be data driven. The obstacle that seems to be preventing us from making better progress is all around the area of comparable data. When we eventually produce a report and come to conclusions, it is essential that this be one of its key questions: how do we better enable those involved in healthcare, North and South, to be able to analyse data? This is particularly relevant as we are move towards improvements in technology and different apps that are used in healthcare, North and South, as well as increases in data storage in hospitals. Notwithstanding everything that has been said, how do we get to a stage where we improve data collection so that patients on both sides can benefit? I will start off with asking that basic open question.

Going back to the OECD and Eurostat, they are organisations that put a lot of resources into ensuring that there is comparable data. It may be that we need something similar in the Republic of Ireland and Northern Ireland, such as an organisation that is committed to ensuring there is a minimum dataset that we are confident is measuring things on a like-by-like basis, and to go from there. It is not necessarily going to replace the data being produced by the two jurisdictions. They probably have good reasons for doing things differently. Healthcare workers may even be called something different on both sides of the Border. It is about stepping back, identifying the things we regard as important and putting effort into ensuring they can be achieved. It should also not be done on an ad hoc basis. We should not come in at one point in time and look at something and then it is followed up on three years later. It has to be done an annual or some other sort of consistent basis. It has to be resourced. There also needs to be a conversation about what data we would like to have at the beginning and to grow from there.

There is a wee bit of an irony when one looks across Departments, whether it is the Department of education, housing or any other aspect we look at. The health systems on both sides of the Border probably collect more data than any other Department, respectively, yet there is the lowest level of consistency across the datasets in terms of allowing research of a comparative nature. You would imagine these organisations would already have a significant capacity in terms of data collection and that getting some consistency should not be an incredibly difficult thing to do.

Absolutely. We had the Minister of Health for Northern Ireland, Mike Nesbitt MLA, in here last week, as was referenced by previous contributors. He spoke very positively of his relationship with the Minister, Deputy Carroll MacNeill. He also spoke about the importance of data collection. It was a key issue when we had representatives in from the Institute of Public Health, which found it to be in its way and hindering the possibility of progress being made.

Senator Black made reference to the stark healthcare inequalities between Malone Road and Sandy Row. The better the quality of information and comparable data that we have, the better the healthcare outcomes will be for patients, North and South. That is obvious. It is something that we must strive towards and will be at the core of the report we will produce early next year. I thank both witnesses for their time.

Does the ESRI's research take into account those who travel across the Border, North or South, to access services? For example, everyone knows that some of us travel to the North to get our cataracts done. There are probably other areas as well, including people from Donegal going to Altnagelvin hospital for treatment. Do the figures take these people into account?

No, they do not. We do not have access to that data. That is another gap that needs to be addressed. We know anecdotally that there are flows that occur South to North. These things are happening, but we have no idea of the magnitude or what the implications are in terms of the stresses it is putting on the relevant healthcare systems. It is certainly another important gap that needs to be addressed.

The ESRI's research states that the waits for many hospital-based services remain high on both sides of the Border. We regularly hear people bragging in Leinster House about our health system being better than the North's or that we are building more houses. It is not of much benefit to those looking for a house or looking for a hospital bed that we have this sort of toing and froing. One of the things that would be really useful is research into systems that work which we could replicate North and South. Is the ESRI thinking in those terms?

The health committee went to Newry and visited Daisy Hill Hospital. We found out that there is a surgical theatre there that has the staff, but it does not have the money to operate five or seven days a week. One would imagine that would be a natural area for cross-Border co-operation. It could be anything from oral health for children to minor or serious surgeries. It could be a hub. If you look across both jurisdictions, there are probably spaces within the systems for co-operation. If we are talking about the systems delivering for people on both sides of the Border, surely this is the way.

Rather than carrying out research on the number of beds that are being taken up, perhaps focusing on this area would be more useful in the medium term. I understand that the ESRI's research provides key data when we are talking about an all-island health service. However, would the witnesses agree that carrying out research in the area I am referring to would be useful to the systems in both jurisdictions in the short term?

The Deputy made a key point. It is the systems that are important. While the objectives of where the systems want to go might be sort of similar, there are different operational constraints on both sides of the Border.

The Bengoa review of healthcare - I am not an expert on what it meant - was published in 2016 with a ten-year plan. The objective was to focus on preventative care and to have primary service hubs concentrated at community level. There was also stuff on workforce development. There are similar approaches in terms of the system objectives in the Republic of Ireland as well. Since the Bengoa report was published, the Assembly in the North was suspended and we had Covid on both sides of the Border. While spending on health in the North is similar to Wales, Scotland and England, there are historical constraints there that are related to lots of different things, including the Troubles and de-industrialisation. We could name a raft of other issues also at play there. Northern Ireland also has an older population and there are higher disability rates. That system requires greater change and probably has done for a long period of time, despite the fact that everyone knows how the system needs to change to improve outcomes for citizens.

There is a financial constraint there which takes significant amounts of resources that are not available to departments in the North over and above delivering the day-to-day services there are in the South.

There are also the political structures. If you are going to deliver a new system, you need co-operation. For example, if you are going to have hubs, you need to ensure there is infrastructure there and access to public transport to those hubs. If you are going to have workforce development, that needs to be tied up with the Department of education. The way the political structures in the North are constructed, there is much more of a siloed approach rather than an integrated approach to policymaking. Again, that can inhibit the move towards the system change that is needed up there which everyone knows has to happen.

We have two different systems and two ways of doing things on an island where the demographics are not that different. We are probably closer to people living in Northern Ireland than we are to some other Europeans and there is potential or opportunity to look at best practice. If there is something happening in the North that is working, we should be looking at it here. That probably happens more within Ireland now. Some hospitals are taking approaches whereby it starts in one place and then there are learnings from that applied elsewhere.

It is dependent on data at that local level to be able to make those solid comparisons. To some extent, that is what we tried to do with our earlier report. We made the point that in Northern Ireland, GP care is free at the point of use and that is generally regarded as a good thing, while in Ireland much of the population pays out of pocket and that is an anomaly in the European context. We wanted to look at the implications of that but, actually, we did not see a huge amount of implications in terms of accessing GP services. That may be a data issue or there may be something else happening. Certainly, one of the advantages of having these two different approaches on the island with similar demographics is to look at best practice in particular areas, but we have not done it.

Another area would be access to particular drugs. I raised it last week with the Minister, Deputy Carroll MacNeill, regarding access to drugs to treat Duchenne muscular dystrophy. Kids in the North of Ireland get it while kids in this jurisdiction are literally wasting away because they cannot get access to it.

The witnesses also mentioned the Sláintecare reform proposals but again, for any of us looking through a lens on this side of the Border, that process is so slow. It is very frustrating when we talk about relying on Sláintecare.

In the North of Ireland, they were able to bring in a patient identifier number relatively quickly, while we are talking about it taking five years in this jurisdiction. The witnesses also mentioned the various hospitals, the inability to share data within hospitals and the configuration of that. For us, as elected representatives, the frustrating thing if we see this as a priority is the slow pace of change in order to introduce it. We were able to do it practically overnight in relation to the Covid pandemic app and so on. A lot of rules were set aside in that regard but, clearly, given the importance of data-sharing for patients and research and everything else, we need to be looking at something on that.

I am sorry for going over time.

Everyone has come in now. Do any members have anything extra to contribute?

Could the witnesses respond on what I was saying regarding the data piece, if there is time?

Do the witnesses have a response?

The Sláintecare report was published in 2017 and we are eight years into that now. I echo that progress on Sláintecare has been relatively slow, although there have been some improvements in the past couple of years. We also echo the frustration with the lack of a patient identifier. Obviously, there are system level and clinical implications for that but, for the type of research we do, in making projections and looking at the substitutability between services, as Sláintecare would suggest, you should increase provision in the community setting and look at the implications that would have for the hospital setting. However, we cannot do that research without the patient identifier.

It is a real issue. There is the European health data space which is developing at European level and Ireland is part of that. We hope that will not necessarily speed up, but will start to come on stream in the next few years. I echo the Deputy's frustration.

We made an identifier for Covid, for instance, which was developed in-house and came from the Department of Health itself. We have the talent and the ability there. There is just a lack of political will.

The high level of private provision is an extra challenge in the Republic. When one has that mixed system, it is even more problematic to get it in, but it is obviously necessary.

Sláintecare is the model agreed with all parties in terms of universal access based on need, not an ability to pay. Taking Sláintecare as a document, what are the first areas the witnesses would identify in terms of having the minimum data sets? Regarding their work with the shared island unit, are there any other health reports due out or do the witnesses have anything in the system in the health area?

On the issue of GP utilisation, the first thing is lack of data on the number of GPs. There are various numbers in Ireland, so before we even get to Northern Ireland, different sources have different figures for the number of GPs working in Ireland. It is somewhere between 3,200 and 4,500. The first thing we need to do is look at this within the Irish context. Certainly, for the type of work we do, the number of GPs would be beneficial.

The other part of that is the other professionals working in primary care, whether they are a primary care nurse within a general practice or a public health nurse or deputy nurse. That kind of workforce data would be a start. The second part of that is head counts and whole-time equivalents. Not everybody is working full-time. In fact, quite a high proportion do not work full-time. There is some survey data on that in Ireland but very little in Northern Ireland. The number of professionals and data on their working hours would be useful.

Regarding the utilisation of services, something very basic like the number of visits to these different health professionals and potentially outcomes would be helpful. That is not necessarily what happens at the individual level but identifying whether the issue was dealt with in general practice or referred to another professional working within primary care or to a hospital setting.

Things like that would allow us to explore, if we were to have a similar primary care or general practice system, what the implications of that would be. Those are some of the big gaps there that are fairly basic indicators.

As regards what is coming forward, I do not manage that particular programme so my only knowledge is the bits I work on. We have a report coming out early in the new year which looks at North-South differences in disability rates, how they compare, how they change over time, and the types of conditions. We look at severe disabilities in particular. That is probably going to be published in the next couple of months.

I am not aware of any proposals but, again, there is that data constraint. The way the programme works is the researchers will put proposals forward to gather things on which we believe the data exists and we can look at them in our report from a policy perspective. There is then a process through which the shared island secretariat selects the proposals. Unfortunately, on the health side of things, it is pretty constrained in terms of what can be done at the moment.

There is going to be a project in 2026 or 2027 - it has not started yet - which will look at the care of older people in both jurisdictions. It might look at the use of residential care services in Northern Ireland, as well as home supports or services. That is another key area we do not talk much about in the North-South context. In Ireland the majority of the population pay out of pocket for primary care but, for residential care and the nursing home sector, it tends to be more generous in the Republic relative to Northern Ireland.

I will ask my two questions together. In the 2022 report, mention was made of the research carried out by Mr. Shane McQuillan and Ms Vanya Sargent over a decade ago on cross-Border hospital planning. The authors provided an idea or a version of what acute health services might look like if constraints, political obstacles and Border issues were removed. What are the witnesses' opinions on that kind of exercise? Could we benefit from an updated version of that? Could an approach like this be applied to an economic analysis of all-island healthcare? I would like the witnesses' thoughts on this.

Can I just come to the second question in case I run out of time? The absence of mental health, particularly in the first report was something I did want to mention. I assume this is due to the data constraints that have been referenced. If so, this is the big question I wanted to ask. How can this committee help to bridge the gap? What can we do to support the witnesses' ongoing work? What can we do to support them all in the amazing work they are doing?

That report is quite old at this point. They were very prescriptive in terms of what the hospital systems should look like. I know this is an evolving issue, even within Ireland and Northern Ireland of moving from a large number of small hospitals to centres of excellence. We have not looked at it but there is an obvious question as to whether there centres of excellence we could have. Maybe it is located in the North or maybe it is located in the South for particular services that are not used to any great extent but are very important for particular subgroups. There is probably something in that space that could be done to explore that issue.

Mental health services are delivered by a large number of different groups. Within Ireland it is GPs, CAMHS and sometimes in a hospital setting. We do not have data. We know the number of GP consultations a person might have but we do not know the reasons for them. A high proportion of those are going to be related to mental health. It comes back to that minimum dataset. Mental health is hugely important and there will be similarities across the Border. We would need to be quite prescriptive about what data we would need in that context. It might be that it is about measuring the mental health and how that might differ across the Border. It might also measure how people are accessing services to see is it through a GP in one jurisdiction or is it through more specialised services. We need to figure out in that context what questions we would like to answer about mental health on both sides of the Border and then to look at that. It is a tricky issue to address, even within one jurisdiction, so it would need a concerted effort to get something on a comparable basis across the Border, at this point.

It is a huge challenge. We tried to look at the forthcoming report where people are asked the nature of their disability. There are mental health categories in both census datasets and we tried to do some comparisons. However, the categorisation approach is different and the definition and the wording of the questions are different. While we can draw broad conclusions, it is the lack of consistency in the data collection operations that really constrains us from getting a good grasp on that.

How can this committee help? Is there something specific that we can do to support the work?

I think it is specifically either the integration of existing datasets in terms of health and mental health and intelligence that need to be aligned or the development of a new all-island data collection system that collects all the information we need to answer all of the questions that we were not able to answer today.

I thank the witnesses.

One of the things we did not mention is inequality related to how people in the North have a higher level of disability and health issues in relation to the conflict, which we tend to brush over. If we look at the British jurisdiction and the figures for the number of people who are on long-term sick leave, a lot of these are related to conflict and people still trying to deal with that in their own lives.

On some of the things that need to be researched in terms of North-South stuff, access to equipment would be really useful. This could address questions like whether there is a PET scan in this jurisdiction while Altnagelvin does not have one yet and all that sort of stuff. If we really wanted our system to work this is where we would look at it and see where there is availability. This would enable us to move around the system in relation to that. The biggest drawback for all of this is that in terms of our systems working, we need the political will to do it. We need to get past the attitude of, "It might work or it might not". Someone needs to be pushing the system because at the end of the day, it is for the benefit of everyone. We talked about a cost-benefit analysis, shared systems and so on and maybe buying products or drugs or whatever else. There could be co-operation between the two jurisdictions without impacting on anyone's constitutional view. It seems to be a no-brainer in relation to rolling out this system North and South that would work for everyone on the island of Ireland.

In terms of the diagnostics infrastructure, at the time we did the 2022 report there was information on waiting times on diagnostics for Northern Ireland but unfortunately, there was nothing at all published in Ireland. As that has changed, that is something that could be looked at. If a service is close to the Border we can potentially make greater use of it if people on both sides of the Border can use it in that kind of co-operation.

An integrated data infrastructure system is mission critical if we are to have an all-Ireland approach to healthcare that benefits everyone on the island. There are clear benefits to be had there, irrespective of the constitutional question. Regarding the Troubles and mental health particularly, our colleague, Dr. Anne Devlin, has done some work on this. We have published some work that shows a clear link between the legacy of the Troubles and disability and health outcomes.

This will be a quick question. References were made to the hospitalisation rates for two respiratory issues, namely, influenza and pneumonia. There was a higher hospitalisation rate in Northern Ireland versus COPD in the South. Does that relate to the availability of primary care and community care?

Potentially, it does. Because GPs are free at the point of use in Northern Ireland our expectation was there might be higher uptake of things like the flu vaccination and the pneumonia vaccination for certain groups. The evidence would show that it was higher in Northern Ireland. This was pre-Covid and it may have changed in recent years. However, the hospitalisation rate for flu was higher in Northern Ireland. This was not necessarily what we would have expected. There may be other issues for that. It could be that more older people were getting the flu even though they had been vaccinated. The population of Northern Ireland is slightly older. It might also be that they have other comorbidities that make them need hospitalisation. It certainly was not what we would have expected.

I just thought it was interesting when looking at two comparable jurisdictions. I have one final question. Since the report was published in 2022, have there been any significant improvements?

We have not really looked at Northern Ireland since that report. In the Republic, the waiting times for hospital-based services have started to come down, after a real increase in light of Covid and the curtailment of hospital activity. There certainly have been improvements in the Irish context, in that space.

I thank Professor McGuinness and Dr. Connolly. It is all about data. The phrases are often used that "data is king" and "information is king". The ESRI has produced important comparative research on the differences in health outcomes between Northern Ireland and Ireland. This is very important. I will not go over all that was said but the one thing is, as the witnesses said at the start, it is all free in Northern Ireland at point of use whereas in the Republic, we pay when we go to our doctor, we pay when we go to an accident and emergency department, and we pay for prescriptions. The one thing that stood out in the report is that both systems are currently facing similar challenges, including increased demand for healthcare services, increasing expenditure and workforce shortages. This shows us two systems that are diametrically separate but that still have the same major blockages and major impediments to growth.

I thank the witnesses for coming in and thank them for answering all our questions. Our report will be due in April, which is the timeline, so today's meeting will feed into that report. Hopefully we will have you in again in the near future to perhaps give us an update and maybe we could talk about our report that we will have prepared on cross-Border healthcare. A happy Christmas to you and your families.