Today's publication of a report into cross-Border co-operation in health services is timely. With the Health Strategy Review just under way in the Republic and the Acute Hospitals Review Group about to report in the North, it will help to define cross-Border health issues for both.
A joint initiative of Dublin City University, Queen's University Belfast and the Workers' Educational Association, it is the latest in a series of reports aimed at developing co-operation in education, health, business and public administration.
Cross-Border traffic in health services can be the result of an emergency or can occur on a planned basis, with prior agreement of the health authority responsible for an individual's care. As the report illustrates, the level of such traffic is low, at less than 0.3 per cent of all patients treated in the North and only 0.13 per cent of the total in the Republic.
But there is a long-established practice of residents of the Republic accessing care in Northern Ireland through the use of an "accommodation address". It is difficult to quantify the extent of this practice but in certain areas it is likely to be substantial.
The fact that such traffic is one-way, from South to North, suggests patients see definite advantages in seeking treatment under the NHS. Whether this reflects the "natural geographic units" identified in the report or is the result of a perceived better quality of service needs further research.
Another interesting finding arises from comparison of standard mortality ratios (SMR) in Border areas. SMRs are a ratio of actual to expected mortality in a population when age and sex differences are taken into account. Although it can be argued that mortality is a crude measure of health service effectiveness, it is significant that districts in Northern Ireland along the Border such as Armagh, Strabane and Newry all have mortality rates that are higher than average. In contrast, mortality rates for the North-Eastern and North-Western health boards are lower than the average for the Republic.
Proponents of the "bigger is better" school of healthcare will be taken aback by the finding that economies of scale begin to operate at a rather low level of 100-200 acute hospital beds. The authors state quite bluntly that "the argument that services must be centralised in the interest of quality . . . is not supported".
Another blow to the theory that creating a "critical mass" of patients across Border regions would justify an expansion of specialist services is the finding that the use of a service decreases as the distance from it increases. One of the biggest barriers to potential cross-Border co-operation identified in the report is the fact that the economically disadvantaged and those living in rural communities are particularly vulnerable.
On a positive note, the potential for co-operation in primary and secondary care emergency services suggests this is a door waiting to be pushed open. The GP co-operatives in the North-Eastern Health Board and Southern Health and Social Services Board are discussing the possibility of out-of-hours emergency cover for patients on a cross-Border basis; the progress of this initiative will be a good barometer for developments in other areas.
The report calls for greater co-operation in public health; expect to see more joint health promotion campaigns similar to last year's folic acid initiative. With both the Republic and the North facing the same challenges in cardiovascular disease, cancer and accident prevention, there is plenty of scope for joint work in public health.
The report also spells out the need for clearer objectives aimed at overcoming disadvantage in Border areas. And better ongoing funding from the Border health boards themselves, rather than the EU, must be put in place.
If there is one criticism of the report, it is the absence of a patient representative amongst the list of key informants interviewed. There is little doubt, however, that this report will be a major influence on the direction of all future cross-Border health co-operation.