On behalf of the committee, I welcome Ms Patricia McKeown, regional secretary of UNISON Northern Ireland. I thank her for facilitating us at this hour. We look forward to engaging with her as a committee on the work of UNISON in Northern Ireland, particularly the challenges affecting members in the health and social care area. UNISON has for a long time promoted North-South partnership on healthcare through a number of partnership initiatives. We look forward to hearing about those partnerships, progress and key learnings.

The format of the meeting is I will invite Ms McKeown to make an opening statement. This will be followed by questions from the members of the committee. Each member has five to seven minutes to ask questions and for the witness to respond within that time.

Before we begin, I remind members, including those attending remotely, of the constitutional requirement that in order to participate in public meetings, they must be physically present within the confines of the place where Parliament has chosen to sit, which is the Leinster House complex. In this regard, I ask any member partaking via Microsoft Teams, prior to making their contribution to the meeting, to 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 might 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 witness will probably be aware, the committee will publish her opening statement on its webpage following the meeting. MPs participating in this committee session from a jurisdiction outside of the State are advised that they should also be mindful of domestic law and how it may apply to their participation in meetings.

I invite McKeown to make her opening statement.

Behind my opening statement are 40 years of engagement with the National Health Service, or as well call it in the North, the health and social care system. These days, it is under the auspices of the thing called the Department of Health. That name has changed many times, too. UNISON is the leading union in the North of Ireland with over 52,000 members and the largest congress affiliate in the North. We are the largest union in the UK, with 1.3 million members. In the North, the majority of our membership - about two third - is in the health and social care system. The next most significant block is education and there are smaller blocks in the community and voluntary sector, local government, youth justice and private companies delivering public services. Some 80% of our members are women. We are a major affiliate of the Irish Congress of Trade Unions. Our former regional secretary, the late Inez McCormack, and I were respectively the first and second women presidents of the congress in a period of 100-odd years. I stress that, in the past 25 years, there have been the two of us followed by Sheila Nunan from the Irish National Teachers' Organisation, INTO, and most recently the current president, Phil Ní Sheaghdha of the Irish Nurses and Midwives Organisation, INMO. The committee will be familiar with Phil Ní Sheaghdha. Four women in 25 years; we are getting there. I also stress that because I want to say we are deeply embedded in the Irish trade union movement. That is our home. We may be the UK's largest trade union, but we are its Irish section.

We have been a long-standing champion of the peace process, with a particular emphasis on the key role of quality public services in delivering on the commitments on equality and human rights in the Good Friday Agreement. The absence of a comprehensive, enforceable bill of rights, which is one of our key issues, the absence of a needs-based fiscal settlement for Northern Ireland and a continuously unstable Government have left our public services in general, and the health and social care systems and education in particular, in jeopardy. That continues as I speak. The failure to adequately track health inequalities in our deeply divided society continues to be of paramount concern to us. It impacts our members as citizens as well as in their work delivering on health and social care.

We were extremely proud of the first programme for government. Engagement with civil society produced the subsequent first health plan, which was internationally hailed as one of the best around. It made a particular point of prioritising tackling poverty as a key factor in challenging health inequality. Sadly, even though the programme for government of the day identified health as the number one priority, subsequent programmes for government saw it slip down the list. Then, we found ourselves in a position where we did not have a programme for government for 11 years. We have recently had something that passes for a programme for government. Over the past 25 years, health has drifted down the agenda both as a key policy issue and in the ability of our system to deliver to the people. While it is universally the case, I think, across these islands that waiting lists have grown and the budget pressures are fairly universal, we unfortunately top the league table in the North as having the worst of all.

In 2012 we gave evidence to a major North-South health conference on health inequalities. What we had to say was confirmed by the Chief Medical Officer for Northern Ireland, who confirmed that in the ten years prior to 2012, life expectancy had decreased and suicide and premature death had increased. Sadly, that is a continuing and growing problem.

We have promoted North-South partnership on health from the outset. We think it is key. In the late 1990s, with our sister union IMPACT – today's Fórsa - we held a groundbreaking conference on the future of social care in Ireland. We were talking about something that would take governments a decade to catch up with the conversation. We were talking about it then and trying to come up with solutions for an ageing population on the island and how its systems would cope with that.

By 2001 we had persuaded both health ministers North and South, who were then Bairbre de Brún and Micheál Martin, to jointly support the first conference of its type that would bring together health workers, their unions, some civil society representatives and representatives of the health system itself to start a long overdue conversation on what kinds of initiatives we should be considering for the future. That led to the formation of a North-South health partnership, which set itself the task of tackling some ring-fenced or small issues. Actually, they were not small but we were not trying to change the world; we were looking at some immediate issues and looking at an all-island health solution. One of the most obvious was that both systems had trawled the world looking for nurses and had brought them in from places like the Philippines in particular. They had come without any thought being given by the introducing system as to where they might live, what they might eat and what the cultural issues were. In the case of the North, that caused all sorts of difficulties because people went to live where it is cheapest and in our jurisdiction that was on interfaces, which brought with it a rise in racism which continues at a pace today. Those early partnership projects were the bringing together of health policymakers and health deliverers to work out what practical steps might be taken. We looked at disability and employment in the health service and ethnic catering in both systems. We tried to look at the terms and conditions of employment in both but that was a task too far for all of us. I do not think that computer has been built yet. Nevertheless, health inequalities was one of the key issues we wanted to look at as well. That worked very successfully. We had champions in the chief executive of the Royal hospital in Belfast, which is the largest hospital, and the chief executive of Beaumont Hospital in Dublin. They were active members of the partnership and we had a range of trade unions, North and South, involved in it. The work was successful and we had two more of those all-island conferences addressed by Ministers from both jurisdictions. The partnership or social dialogue system here more or less ended with the global economic crisis. That coincided with the end of my presidency of the ICTU - I was at pains to stress that it was not my fault - but it did see the collapse of the formal partnership arrangement in the Republic. There was a formal health service partnership as well. We were engaging with part of that and we kept it going for the next couple of years. My colleague invested a lot of time and effort in keeping it going but it drifted. However, in recent times, about a year and a half ago, we re-established our links with Fórsa. We held a very good North-South conference in Dundalk. We looked at some of the developments across health services in different jurisdictions and parts of the world, looking at primary care, acute care and social care. We thought about how we might shape some more partnership working for the future but that does require some political will on behalf of both health systems, which has not been all that forthcoming more recently in the North. That is not, I must stress, from the people who held the office of Minister for Health but more senior level civil servants who have been resistant to the very idea of health workers and their unions daring to think that we could democratically engage in the construct and delivery of our own system.

We see engagement of the workforce, the unions and civil society organisations as absolutely vital in the design and delivery of health as it should be today. I do not really know how embedded that is in the Republic but in the North, there has been a very serious gap or what you might call a democratic deficit in the engagement of the people, which started at a high point post 1998 resulting in that first health plan with real engagement right across civil society to today, when the opportunity was taken during Covid to pull in the decision-making process to be in camera, as it were, where it has stayed in terms of civil society, patients, workers and unions being able to engage in any meaningful way.

We did create a health partnership in the North about 20 years ago. The idea was there was no other real forum for this conversation about health policy, planning, design or delivery and it consisted of the leadership of the health service unions, the various parts of the Northern health service, the Minister for Health and his senior civil servants. No sooner did it get going than the Government collapsed and it went into abeyance. Then the Government came back and we set it up again; then the Government collapsed. This was repeated several times. Two weeks ago we had a meeting between the Minister for Health and his team and the health service unions to discuss restarting the partnership again. We have got as far as a meeting about a meeting. We will get there, I hope, one day.

Unstable government has been a major factor in what has happened to the health service in the North. Our Government has only been in session for five of the last ten years or 50% of the time. In the previous period there were really long tracts of absent government. Probably one of the most critical times was between 2002 and 2007 because during that period there was a great deal of reorganisation going on, particularly in the English health service. We were in the hands of direct rule Ministers who flew in for an hour or so every so often but imposed on us the current system, which is not fit for purpose. It is in the shape of the English health system. Subsequently Scotland and Wales have taken the opportunity to reorganise their health systems. That is not to say they are everything they should be but Scotland is delivering in a much better way than we are.

We are stuck with something that was imposed on us. We have not had a stable Government for long enough to allow real engagement to take place.

It is ironic that, in 2002, I was part of the congress team that was negotiating with the Permanent Secretaries' team - a Permanent Secretary is equivalent to one of your Secretaries General - on what was called the Review of Public Administration. We were looking at the reorganisation of health, education and local government with a view to streamlining services and making them coterminous and more effective. We spent four years on that programme. Before the end, when we were getting quite close to agreement on a different model for health delivery, the Government collapsed and the Minister announced the mega-trusts we now have in the North. Health trusts were really creations of the Thatcher Administration. The idea was that, if you turned the health service into bodies that competed with each other, they could argue over prices, set prices and set varying and, in their view, competitive wages. It did not work, it is not working now and it never will work. To deliver healthcare, you need a collective, properly organised and properly engaged system. Although it does not work, it is what we are stuck with in the North.

One of the biggest issues we are facing at the moment, which I suspect is an issue for the health service here as well, is that all of this lack of governance, accountability and democratic engagement has resulted in private medicine and privatised social care mushrooming exponentially. We are in a very dangerous place. The money to pay for this is coming directly out of the health budget. Nobody has done any work on whether we are now paying more for less. We know from the statistics that we are not doing better. We are doing worse in terms of waiting lists, waiting times and the increasing crisis in social care delivery. This is the position we find ourselves in.

It can be very frustrating, particularly for an organisation like ours that has pioneered partnership for so long. For 26 or 27 years, we have been engaging with the health service on specific partnership models designed to improve the quality of patient care and the mental health statistics of the workforce. We have won awards for our work. We have been doing it for so many years that it has become second nature. It is a partnership of equals. It is labour intensive, however. It happens at the periphery of service delivery. We would like to see the service delivered in that way.

Our big ask of the committee relates to something that is a matter of concern not only for UNISON. We are co-convenors of an organisation in the North called the Equality Coalition, which has more than 100 civil society organisations as members. We were born out of the engagement on the Good Friday Agreement before the agreement was made. We worked together to influence the equality and human rights clauses of the Northern Ireland Act 1998. We convened the coalition with our partner, the Committee on the Administration of Justice, CAJ, which is our human rights NGO. We have been challenging all core policy issues in this field, particularly the absence of a commitment to a bill of rights. We would argue that, if we had a bill of rights from the beginning, we would not have seen so many government collapses over the past 20-something years. It would have had to persist. Mechanisms that were put in place in 1998 were adjusted with the St. Andrew's Agreement. It is ironic that these mechanisms, which were supposed to safeguard society and protect and promote equality and human rights, have consistently been used to block progress on issues of equality and human rights.

We are saying that the UK Government has an obligation to step in. We cannot survive any longer with an unstable Government. The impact on our health service, education system, public services and so on is very evident. I have a very detailed motion, which we are putting to the UNISON national conference. That conference does not take place until June, however. UNISON has a very strong relationship with the party that is currently in government in Britain. That Government said in its manifesto that it was going to work with the Executive and the Assembly to improve public services and generate economic growth and with all political parties and communities to ensure the stability of government but it has not lifted a finger to do so, even though it is a co-guarantor of the peace agreement. We are putting that Government under pressure to step up, remove the veto, introduce the bill of rights and clean up the mechanisms that are causing our Government in the North to fail.

We ask the members, as the relevant committee here, to use their good offices to exert pressure on the other co-guarantor of the peace agreement, the Irish Government, to see what it can do to improve what is really a disastrous situation for everybody in the North, which has an impact on our peace process. I am sorry if I have gone on too much.

Not at all. It is fine. I thank Ms McKeown for her opening remarks and for taking us through them so eloquently and in so much detail. It is appreciated. The first questioner is Deputy Noel McCarthy.

Like the Chair, I welcome Ms McKeown and thank her very much for her opening statement. It was very precise and very detailed. We appreciate UNISON Northern Ireland's long-standing role in supporting public service workers and contributing to stability and social aspects in Northern Ireland. The Good Friday Agreement recognised the importance of equality, economic opportunity and cross-Border co-operation as foundations of peace. As Ms McKeown has said, UNISON has been working on this for nearly three decades. I compliment the union on the work it does for front-line workers in Northern Ireland.

I have a few questions, if Ms McKeown does not mind. She has probably covered some of them in her opening remarks. From UNISON's perspective, how are funding pressures affecting public services, especially with reference to health in Northern Ireland?

The Nevin Economic Research Institute has done work on this, which is totally endorsed by the Irish Congress of Trade Unions. We are underfunded. We started from a very bad place. Throughout the conflict, the UK Government top-sliced the money for Northern Ireland, taking it off our health, education and housing budgets in order to pay for security. We argued that, following the Good Friday Agreement, it should replace that money. You could call it reparations. However, it did not do so. We did not start off with a level playing field. We started off with a major deficit in funding in the context of our public services and we have never caught up. We are currently pushing our own politicians to negotiate with the UK Treasury. The current Government has said it is giving a rise to 124%. That will not meet the need according to the work of a number of the most reputable organisations. The Welsh Government took seven or eight years to negotiate with the UK Treasury to get an uplift, which put it in a good position and kept it in there for a number of years. Our Government was absent for most of that period. That is one of our problems. We have not had the people in place to advocate for us. With regard to the current UK Government, congress met with Keir Starmer when he was in opposition.

We meet on a regular basis with the current Secretary of State for Northern Ireland. They are negative in terms of wanting to increase the money available to us.

That is disappointing to hear.

We lose out in this Barnett formula, to be honest. Many years ago we got to meet Barnett who created the formula and he said that, basically, he worked it out on the back of a fag packet. I think that is absolutely true. There is a lot of nonsense talked about how sophisticated the formula is, but it is not sophisticated and it is not needs-based.

Are recruitment and retention at crisis levels in the particular sector of health? Is it hard to recruit staff and to retain them?

It is not in a particular section. Nursing had a major impact and we sought out nurses from overseas and we still do. It is across the system because we currently have front-line health workers in support services and those support services are vital. Hygiene was one of the biggest developments in health in the 20th century. Those support workers now regularly find themselves below the minimum wage. We have had to take industrial action since 2019 across the entire health system - I am talking about all occupational grades, bar doctors - just to get the pay that had already been awarded into people's pockets. It is ridiculous that we have had to take consistent industrial action just for them to get the pay they had already been awarded. That has had a very chilling effect on people. We have lost lots of expertise in the system. If someone can earn more money behind the cash register in a supermarket than in delivering care, he or she will go to work in the supermarket. That is the kind of thing that has been happening to people we represent.

It is very disappointing to hear that front-line workers in very important roles are not getting the proper-----

They are not getting the proper wage, and are in fact falling below the minimum wage on a regular basis. We have launched a campaign. We have a commitment from the current health Minister to pay the real living wage, as set out by the Resolution Foundation. It is one thing to get the political commitment but with the next breath we are told they have not got the money to do that. Given the majority of quality healthcare is delivered by human beings who are called health workers, you have got to have the money to recognise, value and reward them.

That is disappointing. If I have time for one last question, Chair, I will be very brief. What impact has the Windsor Framework had on public services?

My colleague who could not be here today, John Patrick Clayton, who is the head of bargaining, represents Congress on the UK committee that has been established. I do not see an immediate impact from the framework. There was a lot of talk that we might end up with shortages of drugs and stuff like that. We are not seeing that impact. We do see the impact of having many of our eastern European workers go back home. They are perfectly entitled to be here but they go home because they choose not to put up with the hassle. We have a great number of nurses and social care deliverers in particular who are working on visas, including sponsored visas. We are in the middle of a big campaign because the UK Government has taken some outrageous decisions on how those people will be treated. For example, we have nurses who may have come from Africa or India on sponsored visas. The deal was that if they worked with us for four or five years, they would qualify for residency and would be able to bring their families when the time comes. Now they are being told with the proposed legislation in Britain that it could be ten, 15 or 20 years and they cannot bring their relatives. Again, why would they stay? That will be a further loss of expertise and commitment.

I thank Ms McKeown for her responses and thank the Chair.

Deputy McCarthy leaves the best of the questions until last. There could have been a long answer to that question.

Go raibh maith agat and fáilte. I am really delighted Ms McKeown can be here with us. The committee is looking at an all-island health service and what something new might look like in terms of the delivery of healthcare across the island. What we have been hearing from witnesses and experts within the system is that we cannot possibly present a healthcare system that will deliver optimum outcomes without doing it on an all-island basis. Ms McKeown, UNISON and the other unions have an absolutely vital role to play in imagining what we could have as something new. Ms McKeown will agree that we need a new approach to the delivery of healthcare. I note her comments on privatisation and all of those things. Many of the things in the North are also happening in the South, albeit the North is in a very constrained situation. Specifically, what are the key changes that need to be made to deliver healthcare on an all-island basis, particularly in relation to workforce planning, technology, alignment of systems and collective bargaining? What role can UNISON play in designing those new systems?

I will go to first principles before that and say that we believe in the founding principles of the NHS. We believe that the Welsh socialist got it right, that you deliver healthcare to the people at the point of need, and it is free. That does require a taxation-based system and one that has democratic involvement. The nearest model, and one we have been envious of for a very long time, even though the place has been collapsing for political reasons, is the Cuban health model. The Cuban health model really front-loads primary and community-based healthcare. It has two kinds of hospital systems: the type of hospital one has to go to for medium-term illnesses and the hospital one goes to for the big illnesses, such as cancer and illnesses of the brain and heart. The idea is to keep people out of the top hospital, to get people to take as much control as they can of their own health, and to let them understand what all of that means.

A very cynical view about all of that was expressed by one of our DUP health ministers. We talked him into going to a major international health conference in Cuba some years ago. He went along with the chair of the Assembly's health committee at the time. We also spoke to the Cuban health minister and organised for our health minister to address the conference. He was not from a sovereign country but they made space for him to speak. I asked them to ensure he saw the Cuban health system in action. There are about 12 million people in Cuba. The country has been embargoed for years, and resources are limited, so how on earth are they delivering some of the best health outcomes? That did happen and I think he came back with a very changed view. We have spent some time over the years bringing some of the leading experts on the Cuban health service to talk. This is a small island. There are fewer than 2 million of us in the North.

If you add up everybody on the island, you will find that we have less than half the population of Cuba. However, we have much more in the way of resources and money. It is about how we decide politically to deal with that. If it is taxation based and free at point of need, there is absolutely no reason for a health system to be overburdened with bureaucracy.

My colleague who has recently retired came to us after many years working with SIPTU. She would have been familiar with the health service in the Republic. She worked with us for 14 years in the North. She could not believe how many layers of the onion she had to slice away to try to find out where decisions were made, who was accountable and who was responsible. All that should be simplified in one system for assessing need and delivering need.

There is no need for an internal market, which was part of the health service logic in the UK. That is an invention created by people who want to make money out of healthcare. There is no need for internal markets. We need to be honest about the privatisation of healthcare on this island. A hospital in Mullingar was set up by doctors, at least one of them a retired consultant from the Mater Hospital in Belfast. It then used the North-South health directive to make a lot of money. There is a private hospital in south Belfast which is now fully staffed by all those guys who have health service contracts but their contracts also allow them to engage in private medicine. They are in charge of supply and demand. They can do six procedures in the health service under their health service contract and they can do 12 of them in the private sector, which is paid for by the health service, in the same period of time. How can that be justified? There are vested interests, greed and bureaucracy. All those things need to be tackled and they are on both sides. They are not unique to the North.

Those years of engagement in the health service partnership have told us certain things about how the world works. All of this needs open and honest conversation. If we want to reorganise the health service, we need to engage with the people. What we are missing and which is necessary in the North is some kind of people's assembly, some kind of civic forum around all of this. Someone needs to take ownership of these systems. So, before I would even get into talking about what the bargaining structures or anything else might look like, these are the things that have to be put right first.

I have asked that the books be opened. The lion's share of our budget is spent on health and social care in the North as it rightly should be. However, what are we spending it on? Is a mystery. They need to open the books and tell us.

I am conscious of Ms McKeown's time. We have about 35 minutes left for questions and answers.

I am okay.

I think Ms McKeown said there were three all-island conferences. In what years did they take place?

I made this little milestones booklet to celebrate the 25th anniversary of the union. It is all in here. The first one was in 2001 in Dublin. The next two were in Belfast. The second one was in 2005. By that stage I think the Minister was Mary Harney. Is that right?

That would make sense.

I think there might have been one in between.

Also in terms of that engagement, Ms McKeown mentioned that there were the North-South health partnerships as well. What was the most fruitful part of that engagement? We have obviously engaged with the Minister for Health in the North. We have looked at systems. We have spoken to colleagues at Stormont. Digital health records are now available to citizens in the North but not here. From those early stages, looking back on it now with benefit of hindsight-----

What proved fruitful was people who had never done so before meeting and talking to each other, not least the chief executives of the major hospitals on both parts of the island. William McKee, who was the chief executive of the Royal Hospital, died before his time. He died at the age of 66 from cancer. We lost a champion there. I am not seeing a replacement for him at the moment. From our point of view the very first time we had that engagement, we were bringing some health workers who had never crossed the Border before. I can remember the comments being made on the Enterprise as it went across. They were a wee bit wary about the whole thing, but not when they actually swapped pay packet information and realised what their counterparts in the hospitals in the South were being paid. Certainly, it was a case of saying that they needed to do more of it.

The imprimatur came from both governments, the Ministers and the Departments. There was not big finance but the fact that some finance came from both those Departments and we were accountable back to them again was important. The early pushes led to what became the memorandum of understanding. We wanted that memorandum to be enacted seriously during the Covid pandemic. As we said to our own government, "This is an island and there is a memorandum. If we're going to have a strategy to tackle this if has to be on that basis." It was not properly implemented. I have seen some developments on the sharing of health services, as with Altnagelvin and cancer services, the Mater and child-----

From what Ms McKeown is saying,-----

There needs to be more of that. We are continually being told that health services or acute services have to be removed from X place, usually a rural area, because there is insufficient volume to keep up the expertise required. There is plenty of volume if the medics travel, including travelling across the Border.

From what Ms McKeown is saying, there should be that level of engagement once again.

Absolutely.

What would it take to re-establish that, both the partnerships and the health conferences, to the scale of the past? What is the missing piece?

We had to establish political will at the level of government through the Ministers. We did our main work on that with the senior Civil Service teams in both health Departments. We then had to find the champions on the senior management side, the CEOs. If a right-thinking CEO buys into it, then the rest of his or her team is expected to buy into it. We had to do the same thing with our own people. Sometimes that means investing some time in working out what we mean by partnership, how that partnership should operate and what the common interests are. Are there obstacles or roadblocks? How should we deal with that when we come to them? We have done a lot of work on that front over the last 25 years.

Ms McKeown mentioned pay. There was obviously a pull factor into the Republic for staff who might have been recruited in the North and ended up coming south. If there is a will within Unison and its counterparts in the South, how do we get that re-engagement again, that political will, that drive of senior officials within each Department of Health? How do we get that started again?

We are up for it. We played a vital role in making it happen in the first place.

Is it being pushed again?

We have got the commitment to do that. The players are significantly different now. A lot of the people who engaged back then have left the field. It is perfectly doable, however. The first time we worked on the partnership idea, we did so with Bairbre de Brún. During the second time, the next champion was Michael McGimpsey. Those two people had a particular affinity with workers in the health service and the idea the union was coming forward with. That makes a genuine difference.

I thank Ms McKeown for coming before the committee today. I have a couple of quick questions because I am conscious of time. Given that 80% of UNISON membership is made up of women, I will touch a bit on the gender disparity in the health and social care sectors and the potential for the exploitation of women and migrant workers, particularly if we continue to invest in privatisation. Maybe we could benefit from having a shared vision or protocol on these issues. That is something on which we could work together on a North-South basis. I would love to see that.

If I am not mistaken, UNISON has both a national women’s committee and a migrant workers network. The union played a crucial role in campaigning for the employment rights Act. I would like to hear Ms McKeown’s take on these issues and whether she has any recommendations for this committee on how we can improve inequalities and any ways we can intervene so that our counterparts in the North can do the same. Will she speak a little bit about that?

We have always played an active role inside the structures of the Irish Congress of Trade Unions, ICTU. We have been part of congress's women's committee in the North and we engage with the women's committee in the South. We have spent the past 30-odd years engaging in women's conferences of the ICTU. There is one coming up in two weeks in the Slieve Russell Hotel in Cavan. It is a biannual conference. There is a biannual seminar in which we share all these ideas and then there is a biannual conference, which is more formal in its approach.

We have initiated and have been part of big programmes, such as making abortion a trade union issue. That was part of work where we engaged with women on an all-island basis on a whole range of issues. Before that, we pioneered domestic violence policies and action programmes, particularly in the health service in the North where we won the support of management. This is a very straightforward issue in a workforce of 60,000 people, who are the directly employed people. Where individuals do not come to work, have irregular sickness patterns or regular unexplained sickness patterns, domestic violence tends to be in there somewhere. Those programmes have been very important to us.

We have a whole structure of self-organised groups, including black and migrant workers' groups as well as LGBT+ groups. The women's group is the longest and most active of all those groups. There is also a disability group. Those structures are all in place because, essentially, women in the union fought for them decades ago and broke barriers. In more general terms, those inside of the Irish trade union movement also fought for them and broke barriers. This committee is talking to the union that put rape within marriage on the agenda of an ICTU conference some 35 years ago. We were told that it was not a trade union issue, but it is now. No one would dare say those things now. The sharing goes on but in the context of the collective bargaining process, we must always keep an eye that the good policies we are pushing at one level make their way onto the proper collective bargaining table in order that we do not just have a policy but, rather, a real action plan that turns some of this stuff into reality. It is difficult stuff but it is the lived lives of 80% of our members in the union.

I will come back to something Ms McKeown said at the end of her opening statement because I would like her to expand on it and on her ask of this committee. She may have touched on this while I was not here. I apologise but I had to run up to the Seanad to attend a vote. Ms McKeown was speaking about the bill of rights and her ask of the committee today. Will she expand on what she would like this committee to do?

Absolutely. The bill of rights was a core commitment in the peace agreement. We fought for it and we particularly argued that it should be legislated for at Westminster because there would never be political consensus among the parties in the North on the introduction of a comprehensive, enforceable bill of rights. That is what we got. That is what is supposed to happen. However, subsequent UK Governments have all sidestepped their responsibilities in this regard, no matter their shade or colour. The current position is that the UK Government will move on legislating for a bill of rights if there is political consensus in the North. I challenged that in the last meeting congress had with the Ministers.

We have spent 30 years working on a bill of rights. There is a draft bill of rights that human rights lawyers, working with civil society, have put together. It has been around for a while. The mechanism by which this was supposed to work was that the Northern Ireland Human Rights Commission, NIHRC, would engage in a consultation process and, out of that process, a set of rights would be developed that would be passed to the UK Government to legislate for. That has happened time and again. The most comprehensive exercise was in 2010 when the Government in the North had collapsed again, as usual. All the political parties were brought together for a full year alongside all the key players in civil society. We had an international chair. I chaired the social and economic group on behalf of the Irish Congress of Trade Unions. We spent the year working out all the aspects of civil, social, economic and political rights and the key elements we wanted to see in a bill of rights. When that work was done, we passed it to NIHRC. It pared down and translated it into another document to demonstrate what a bill of rights should look like and gave it to the UK Government. The UK Government, after thinking for two minutes, responded by saying that we can have the right to vote and engage in political life. Talk about making a mockery of a commitment that was vitally important.

We sold the peace agreement to our membership. At the time, we wrote to every single member of our union, of which there were 32,000, with an eight-page document outlining the reason they should vote "Yes" in the peace referendum. It also outlined what we believed the main commitments in the Good Friday Agreement would mean for them. We emphasised public services as the vehicle to deliver the promises on equality and human rights. We said that we would end up with a better society – maybe not necessarily for everyone who was immediately going to vote but certainly for their children – but we have not ended up there. We have lost a whole generation who should have benefited from the peace process. It is a damned disgrace and it is the fault of the UK Government. The Irish Government has had to be put on notice by us through the trade union movement on more than one occasion.

Cuirim fáilte roimh Patricia McKeown. She is very welcome. In her opening statement, Ms McKeown made reference to migrant workers experiencing racism, particularly healthcare professionals and those across the public service.

To what extent do these workers engage and become members of UNISON and other unions? Will Ms McKeown tell us a bit about that? Regarding the nature of the racism they have experienced, Ms McKeown mentioned they experience it particularly in areas where accommodation has been most affordable and interface areas. She said nurses from the Philippines had experienced racism of this kind. Have similar incidents been experienced by any other particular ethnic groups?

At a very early stage, we worked with a body called the Northern Ireland Council for Ethnic Minorities. UNISON was born in 1993 out of a merger of three well-established public service unions. That gave us the opportunity to start looking at a lot of things in a different way as the new rules were written. That is where all the equality and self-organised structures came from. We worked at an early stage with the Northern Ireland Council for Ethnic Minorities and we asked it to identify where the key groups are. It came back and said it had virtually no membership because the people from black and ethnic minority backgrounds tended to be the professionals, such as doctors in the health service. We had very few nurses at that point and virtually no support workers. We were able to identify two people at that stage. However, we worked with the council anyway on the key racism we detected from conversations with our members, which was against the Irish Travelling community. Its members experienced major racism. We worked with them for several years.

When the health service opened up to go searching for those nurses around the world, we learned at an early stage that if you wanted to encourage them to join a trade union, you had to understand that some people were coming from places where they faced repression if they were members of a union or from places where unions were seen as one of the repressive organs of the state they had come from. We had to learn very rapidly different ways of having conversations with people. We are today the largest organisation of black and ethnic minority workers in the North. That is after 20 years of serious commitment and putting resources into the issue. We already had an indigenous black member of staff on the administration side but we have just appointed our first organiser who is from Nigeria. That is going to be another door that has opened for a community that is settling and is entitled to settle.

In one night, six of our nurses in one estate in Antrim were put out of their homes by the racists, who are essentially paramilitaries, no matter what anybody says. Our local people were later told by these people that if they had known they were Filipino and nurses, they would not have done it. That is hardly an excuse. Our members have suffered physical and verbal abuse. Their children have been intimidated out of their schools. The Islamophobic side of it is particularly vicious at the minute but it does not matter if you have a different skin colour as the people who are doing this do not distinguish. It is a major issue. We have argued that it has been left almost solely to the police, who have worked with our people, workers and employers. It has been left almost solely to them because we are not seeing the joined-up approach to this issue we need to see from government and other agencies.

I will intervene here to steer the conversation. In the limited time we have left, will Ms McKeown comment on whether this is something that has been common to other migrant healthcare workers or was it primarily those, such as in the example she gave, from the Philippines? Regarding what Ms McKeown said on the paramilitary involvement in racism, have any migrant healthcare workers reported instances of where they were targeted for protection money or something along those lines?

That has been going on for years. Come on; it is the North.

Is that something that is commonly reported or is Ms McKeown saying it is something that is taken as a given?

No. You are more likely to get that with local businesses, the construction industry and so on. You are not going to get it in the health service or the education sector. It does not happen so much in the public sector but the intimidation goes on and there is growing, almost rampant, racism across this whole island. It is not any different here. Some of the characters pushing that agenda may be different in their background but they are essentially the same fascists and racists who are doing it, whether they are in Cork, Belfast or the west.

We have been meeting with the PSNI section that is trying to deal with racism. We do this through our Equality Coalition, the body I spoke about, and with civil society organisations. We have a monitoring group so we have been keeping an eye on this at local level. We have people at local level recording and videoing the intimidation and attacks in some cases. We are passing that material through and saying we want action taken. My own union representatives, such as the elected shop stewards and people like that, have had to tackle a fair bit of this. While it does not happen much in the workplace, it does happen in the workplace, so we have a special mandatory training programme now for all our staff and elected representatives at local level. It has taken a while to work through because it is involves about 1,000 people. The programme is about how to challenge all of this. Congress has a very good programme which was part-funded by the shared island unit and has developed tools for having these very difficult conversations. This is happening at people's kitchen tables. It is not somebody else doing all of this. This is even within families now. The idea is that people start having conversations to tackle these issues and that their first port of call is not to hit somebody over the head because they do not like what they are saying. However, the truth of the matter is that there are some people in this society whose attitudes will not be changed. We have to guard against that.

We have Ms Claire Hanna MP online.

I thank Ms McKeown. It is good to see her. I concur with a lot of what she said about the need to create something new and better and the fact that most of the gains of North-South health have come from motivated people and divisions within the health service, rather than being political gains. In a number of the stories she told us there, Ms McKeown brought up the stop-start nature of the Stormont Government, which was writ large throughout her evidence. The toll on the health service is very clear, as it is in other public services. It is also clear in the failure to have a bill of rights in place. On the matter of Stormont disappearing for years at a time as well as some of the logjams, would UNISON Northern Ireland support publicly or consider, when it is engaging with political parties in the run-up to next year's elections, campaigning on the issue of Assembly reform and the need to change some of the government structures to ensure continuity of government and stability to deliver on those issues?

Just in case I run out of time, Ms McKeown rightly referred to the appalling racism faced by a lot of UNISON’s members, and I really want to commend UNISON and many of its partners for standing by their workers and being the first out of the traps to educate people as well as protect and stand up for workers. Ms McKeown mentioned the fairly irrational and mean-spirited UK Government-proposed reforms, including a stretch in the contract it has with people in terms of leave to remain and people gaining status after investing their years. Is that something UNISON is getting political engagement on in the North? Is the Executive weighing in, given that our health service would quite simply collapse if we did not have those workers? Is UNISON finding that political leadership in the North is stepping up to the plate in terms of making that case for its workers and the health service across the board?

Is Ms Hanna asking if we are getting a response from politicians, the Executive and the Assembly?

Yes. On those two issues, are they using their influence with the UK Government to make clear that those immigration reforms would be a disaster for UNISON workers and, therefore, for the health service?

I am not sure we have asked them yet. We have just had a major lobby of Westminster. We sent about 30 of our members-----

I know. I met them. I think I was the only MP who did.

Yes, we met on this.

The power of the Executive is there as well. Its members are in constant contact with the UK Government.

I take Ms Hanna’s point. We met her because we were meeting the Westminster politicians from the North, given that was where the voting power was going to be. I am not sure we have directly spoken to the Northern Ireland Executive, but I will take the point on board. There may be some benefit-----

I would like to think it would have some meaning if the Executive said it could not deliver the health services required if these workers were not here and they should be-----

We would not do it exclusively on the health service but I have to say that is where the majority-----

UNISON is a health union.

Yes, that is where the majority are. Do not forget that quite a lot of the workers affected are working in the privatised social care sector.

That would also be affected. I do not know that that undermines the point I am making, which is about those workers and the political support for them. All parties need to tip in on that.

To go back to the question about reform, Ms McKeown spoke very clearly about how, in her long experience, the scarring times that Stormont had not existed were still felt in the health service. Will the union campaign, or at least use its influence with politicians, to address that?

Can Ms Hanna repeat that?

For example, UNISON campaigns correctly and extensively on the bill of rights as a way to underpin good government. Over the course of the past two hours, Ms McKeown has numerous times referred to the scarring impact of the absence of Stormont. Is Stormont reform something that UNISON would therefore campaign on as it rightly does on the issue of the bill of rights?

I have told the committee that there is a very important motion I am putting to the UNISON national delegates conference. That will not take place until June. I have asked the committee to intervene with the Government here. Our motion is about intervening with the UK Government on the need to interfere now and reform the mechanisms that are being misused, in particular the veto that is enshrined in the St. Andrews agreement and to replace that with a bill of rights. There has been enough messing about for the past 26 years. It is either a real commitment and a peace agreement or it is not. We are sick and tired of various governments side-stepping their responsibilities on this. The irony in the very mechanisms that were introduced to protect progressive and rights-based legislation being used to block it is no longer tenable. It really is not. Ms Hanna knows that and I know that.

I thank Ms Hanna and Ms McKeown. We have two remaining questioners, Deputy Crowe and Mr. Hughes, who is online. I call Mr. Hughes.

I thank Ms McKeown for her contribution thus far. She alluded in her opening statement to the racism that had been targeted at members of staff in the health sector broadly. I commend the role that UNISON played in supporting international staff and combating the odious incidences of racism last year in Daisy Hill Hospital in my constituency. We know that it was the international recruitment programme that stabilised services there and that these workers are a welcome and important part of our community.

On the theme of health more broadly, I welcome the commentary in Ms McKeown’s opening statement in relation to health inequalities and the class dynamics that contribute to those. It is a depressing reality that the poorer you are, the sicker you will be and the shorter time you will live. North-South collaboration is practical and good for efficiency, but improved healthcare outcomes for patients and conditions for staff remain arguably the most potent selling point for greater collaboration on a North-South basis going forward. In that vein, and regarding the challenges that have been addressed by some of the other speakers and by Ms McKeown in terms of recruitment and retention of staff across the entire health and social care sector, how much does she attribute those to both the push factors of conditions in the North, the pull factors of higher salaries in the South and, in essence, the lack of a joined-up strategic staff and future planning environment on an all-Ireland basis? What does she think of the potential of enhanced collaboration to address this in the medium and long terms?

I am optimistic despite everything I am saying about the disastrous situation we are living in. I really do think that there is a conversation happening that is different from conversations of the past. It is one around putting some things on the table. Most of the people I know would not have voted for this peace agreement if there had not been a clause in it that said that, at some time in the future, the constitutional position of this place was going to change. Otherwise, why would they have voted for it? I was very worried about some of the stuff in the peace agreement because I was very worried that I would end up not being an Irish citizen, but I believed all the things that people said in the background and I voted for it. It takes me by surprise when, 26-odd years later, people say they did not know that clause was in there and ask why we are having this conversation. It is time to talk about a new kind of future and have a dialogue that is much more open.

I got the shock of my life when I became, first, the vice-president and then the president of the Irish Congress of Trade Unions. That spanned a period of four years. In the North, we are always making sure that the motions we write are North-South. We are trying to encompass the views of workers and policy across the island. I held those positions and, suddenly, I was looking from Dublin to Belfast and the Himalayas were in the way. Honestly, there has been too much for 100 years of people doing their own thing in separate developments, and there needs to be an awful lot more coming together and having conversations. It came naturally to us as an affiliate of the trade union movement because we never saw those barriers really. We only started to see those barriers when we got to a place of dealing with governments and those North-South bodies, for example, that were set up without trade union input into them.

Inez McCormack became a member of InterTradeIreland because the Irish Government nominated her, not because it was giving a seat to the trade union movement. I followed her into that seat. When I finished my term of office, the seat went and there was no trade union engagement. Trade union engagement across the island will make the difference. We have been frozen out of trade union engagement in most of the key decision-making public bodies in the North over a period of 30-odd years. These are places where even in legislation we had rights to be. That legislation was changed and we were put out. That is one of the key issues.

To go back to square one, I remember why we are the trade union movement and why we want to shape the society we live in. I remember that it is not about borders but about breaking down borders. I remember the arguments in the early days when we said sex discrimination or sexual harassment does not stop at a Border sign but happens across all workplaces, across the whole island. All these things need to be taken on that kind of basis. If we were to do that, we would start to have a better idea of how this peace agreement should be implemented.

Mr. Hughes is absolutely right that the poorer you are in this society, the more likely you will remain disadvantaged for the rest of your days and die young - and die of something that probably could have been cured. That is among the worst of statistics that came from all the work we did on health inequalities. If you were to take a bus journey from one end of Belfast to the other, as to who will live longer, the life expectancy would have a nine-year differential in the context of whether you were living in a poor or working-class area or in the nice leafy suburbs. That is in one city, but that city has 70 separation walls and barriers to this day, so we need not kid ourselves that we have secured peace because we have not. We have a deeply divided society but it is also divided on the basis of who gets fair treatment and who does not. If we had a comprehensive, enforceable bill of rights, the lives of so many people, but particularly the most disadvantaged, would start to change. I want to hear everybody who really believes in this peace agreement to argue for that very vocally.

Cuirim fáilte roimh Ms McKeown. Save the good wine until last - you know yourself. Hopefully, Ms McKeown will be on the road shortly.

I would have liked to get into discussing the impact of the racist stuff in the North. For those of us of a certain age, the images of one of these pogroms that were going on, with people putting signs in their windows saying "I am a local", brought us back to years previously and the image of the Tricolour beside the Union Jack and a bunch of racists together going off drinking in a loyalist club. Anyway, I will park that. Unfortunately, we have racists on this part of the island and in the North.

We also have a two-tier health service in the South and the North. Ms McKeown mentioned that. She also mentioned the mushrooming and the normalisation of private medicine in this State, the challenges that exist and waiting lists getting longer. People think of the North and hear "Get up and get your eyes fixed or your hips done" and so on, and they think skipping the queue in this State will solve the problem. We have those inequalities.

One of the things I am surprised no one ever talked about post Brexit was the European health insurance card. I have one here. People in the North do not have these cards. Ms McKeown is an Irish citizen. She has lost that.

No, I have got one in my handbag because I am an Irish citizen.

Well, you still have it. However, you will lose it-----

I also have the global card issued by the UK because, under the terms of the Good Friday Agreement, can I not be both?

You can.

One of the challenges many people talk about is the shared data stuff, which is a big issue. Again, they are different systems, and we have different systems in this jurisdiction as well, with hospitals not being able to talk to one another. How important would Ms McKeown see that as? There is a patient identifier number in the North now but we do not have it in the South, and we are talking about a number of years. How important is that? How important is it that the systems would be able to talk to one another and exchange information? How important is the fact that we have a system whereby there is complete co-operation in relation to animal health but that there was divergence when we had the pandemic? Ms McKeown referred to divergence. Most of us on the island get the idea that we want a health service that works and delivers for us all. It makes sense that if people are sick and if there are supports on one side of the imaginary line that is there, people should be able to access them. If it delivers for those people, that is really important. For a lot of people in the North, there was also the pride in the National Health Service, but there has been a lack of investment in that for decades. It is getting worse and worse. Here, the lists are getting longer despite the fact that any amount of money seems to be available in that regard. If Ms McKeown had a wish list in relation to some of the services that we could co-operate on, how would she, regardless of jurisdiction, deliver those services?

Data systems talking to one another is really important. We have gone through various iterations of patient information systems, etc., in the North, and zillions have been spent. With health service payroll, zillions have been spent on wrong systems, systems that are not fit for purpose and systems that do not talk to one another. The GPs' new system is not talking to the new patient system on the hospital side. Of course, we are also buying this from entities like Oracle, which is complicit in genocide. Nobody is having conversations with us about whether that is the right procurement route to go down. When we set up the North-South partnership several years ago, one of the reasons we could not do a great deal about trying to compare the jobs and the terms and conditions was exactly that the data were held in very different forms. With some political will, however, you could do it. Somebody would make a killing on the IT front, but if it is the right system - and a proper ethical system with proper ethical procurement - would that not be a good thing to do? I would think so. We also have a great deal of expertise in our own ranks across the public sector, North and South. I do not know what happens here, but in the North we seem to tend to go get ourselves a consultant at the drop of a hat without looking at the fact that there might be people actually working for us who have lots of expertise.

That is what happened in the South with the patient identifier number during the Covid pandemic.

It is disregarding and undervaluing the people who work in the system. There is simple co-operation that could be engaged in. There is some simple co-operation happening at the minute. We lost some of the key cross-Border health delivery systems when Brexit impacted on us.

A little bit of that slack has been taken up by the PEACEPLUS funding, but if I were a member of this committee, I would start digging into where the money is going in terms of who is benefiting. There are wonderful clinicians saving lives and doing really innovative and important things every day, but there are also some greedy people around. I am just asking who has pole position at the minute. Is it the greedy people or is it the people we really should be supporting?

Ms McKeown mentioned the challenges in relation to the separate trusts-----

We do not need them.

In this jurisdiction, we are very much going down the road of decentralisation. Would Ms McKeown have any worries that, to some extent, we are mirroring a system that clearly has not delivered in the North?

Yes.

People are very worried that they would lose their trusts. They are worried that if they lose that trust, the system may get worse rather than better. Is that one of the biggest challenges?

I find that when you talk to people and they tell you what is important to them, you can separate it out from the nonsense. I have lived through I do not know how many iterations of governance of the health service in the North - some of them good, most of them absolute nonsense. Most were imposed by the British Government in the first place because the people we elected were not in work.

There are solutions. We have many solutions. I could paper this room with the formal consultation responses that my union has produced over the last 30 years to every element of health policy, health organisation and health governance. The work is done, and we are not alone. We have loads and loads of people on the civil society side all thinking the same way about how you can deliver on these things. With the proper political will, real co-operation and some democratic dialogue, you can get there, although you will not get there overnight. None of this is rocket science, but it is made to be so complicated because, ultimately, the vested interests at play make it that way.

I thank Deputy Crowe for that.

On behalf of the committee, I thank Ms McKeown from UNISON for engaging. It has been a while since we had one witness who was able to answer every question from every committee member. That bows to Ms McKeown's experience of 40 years. We thank her for sharing her insights with us this evening. As was said earlier, we have a body of work being done on an all-island health basis. The information and insights given by Ms McKeown this evening will assist us with that. We wish her the best of luck with her own endeavours, particularly around ICTU and all of that. We thank her for her time.

The committee stands adjourned until Tuesday, 21 April 2026 at 11 a.m.