A DUP stalwart travelled with his wife and young son to the deep south during the summer and came back home singing the praises of the Healy-Raes. During his time in Tralee and Dingle, quite by chance, he discovered how the Kerry politicians have become a significant force in cross-border travel.

Jackie, Michael and Danny Healy-Rae are evangelists for the Cross-Border Directive. They and a cohort of politicians including Michael Collins, Robert Troy, Joe McHugh, Charlie McConalogue and Eamon Molloy have mastered the intricacies of a piece of EU health legislation, known in the trade as the CBD (Cross Border Directive).

Financed by this EU measure, not hundreds but thousands have travelled north and returned home with cataracts removed, or with renovated hips or knees and an end to the soul-destroying, painful experience of lingering on a (growing) HSE waiting list.

It's an amazing story. It is well worth understanding because it offers a ready-made solution to bypass the waiting lists that are bedevilling Ireland's public health system. It gives one more insight into how EU membership has very practical benefits for Irish citizens. It has a very real south-north tensions angle. And a Brexit one too.

It is a phenomenon that is going to grow in both importance and relevance.

Image - Thumbs up for the CBD - Michael and Danny Healy-Rae

Thumbs up for the CBD - Michael and Danny Healy-Rae

Monasterevin-born David Byrne had an important role in this saga. He was the Attorney General in 1999 when then Taoiseach Bertie Ahern appointed him to succeed Padraig Flynn as Ireland's member of the European Commission.

Byrne is mild-mannered and could never be accused of having a taste for the limelight. But he is the Irish politician who made had the greatest single, practical contribution to the concept of trans-frontier access to health services for EU citizens.

As the European Commissioner for Health and Consumer Protection, Byrne and his officials shaped and championed what is known as the Cross Border Directive. His five year term ended in 2004 and he was back in Ireland seven years when on 11 March 2011, the provisions eventually passed through all the democratic layers of EU decision-making.

In the eight years since, understanding of the practical benefits of the CBD has been on an upward curve.

Ireland with its disjointed camel, more 'Boston than Berlin' concoction of a public/private health service model is fertile ground for the David Byrne initiative.

Image - Former AG David Byrne championed the CBD

Former AG David Byrne championed the CBD

How the CBD operates is easy to understand. The going rates for medical procedures in the home member state are established. Everything from hip replacements to hysterectomies. The information is made available to the general public – in Ireland's case, a HSE, Cross Border Directive website. (Details about how to access the website are given at the end of this article)

The specified amount then becomes the patient's maximum budget when seeking to have the procedure done elsewhere, rather than linger on a waiting list in his/her home state. If the cost turns out to be lower than the going Irish rate, then the lower amount is reimbursed.

Often the two greatest challenges for the patient are:

• Finding the place in another member state where the procedure can be accessed

• Paying the upfront cost of the procedure and funding it until the outlay is reimbursed by the HSE. (The delay in reimbursement used to be on average six weeks but it recent times it has stretched to three months)

Enter the canny politicians

A number of canny TDs in the southwest corner, the most distant area of the country from the border, were the first to cotton on to the potential of the CBD. A growing number of GPs, a group of politicians and the HSE unit in Kilkenny, running the scheme, are the crucial players in the CBD's increasing popularity and use.

The company that owns the Kingsbridge Private Hospital in south Belfast is also a significant involvement. Its majority shares are obstetrician and gynaecologist, Dr Suresh Tharma and Dr Ashok Songra, a maxilla-facial surgeon.

Four years ago they gave up their day jobs to concentrate on growing their company. They appointed Mark Regan as CEO at Kingsbridge. He started life as a radiographer and then worked for several years in the private sector with Philips. The Belfast private hospital struck the jackpot when it began to make available medical procedures in Northern Ireland for HSE-funded patients from south of the border.

Image - Patients from the south arrive at the Kingsbridge private hospital

Patients from the south arrive at the Kingsbridge private hospital

The HSE statistics indicate just over 2,000 people used the CBD scheme in 2017. 

Last year the number more than trebled to 6,728. The figures will rise sharply this year. 

Expenditure on the scheme grew from €29,265 in 2014 to over €12m last year. It could end up at close to €20m this year - the end of October total was close to €10m but over 3,000 people are awaiting reimbursement. 

Image - HSE Cross Border Directive: Monthly Activity Report (No Of Claims Paid)

HSE Cross Border Directive: Monthly Activity Report (No Of Claims Paid)

Image - Value of the Claims Paid

Value of the Claims Paid

Kingsbridge accounts for over 60% of the HSE's CBD expenditure. According to CEO Mark Regan, earlier this year he welcomed to Belfast the 48th busload of patients, co-ordinated by Cork South West TD Michael Collins and the Kerry Healy-Raes.

In the beginning the removal of cataracts was the procedure required by the hundreds of south west patients. But according to Kingsbridge in more recent times they have diversified into hip and knee replacements.

The typical patient workflow is as follows. Contact is made with a cross-border health provider and an appointment is made to see a consultant. The patient arrivals with a referral letter from a GP and any available recent scans or x rays. A surgery date is arranged and payment options discussed - settlement payment is often sought before hospital admission date. Once the surgery is completed, the discharged patient seeks reimbursement from the HSE.

Patients are arriving North in buses, mini-buses, private cars and by public transport.

According to Mark Regan, the busy period is Friday, Saturday and Sunday. The typical group arrives on Friday and overnights in a hotel. Belfast has a growing stag and hen party sector. Deliberately Kingsbridge uses the upper end of the market, the Hastings Hotel group, owners of Belfast's Europa and Grand Central, to ensure patients get a comfortable night's sleep before their surgery.

The procedure takes place on Saturday, the patient is kept overnight in the hospital and is then discharged on the Sunday.

According to Mark Regan, the excess patients have to pay - the difference between what the HSE will refund them and the charge at Kingsbridge - is a very small percentage of the overall cost. 

It can vary slightly, depending on the euro/sterling conversion rate. Below are cost details of the five most popular procedures for patients who travel north to the Belfast hospital, using the CBD.

Kingsbridge prices and reimbursement rate on 5 most common procedures

• Cataract surgery, £1, 955 per eye (€2,248); HSE reimburses up to €2,211

• Hip replacements from £10, 113 (€11,630); HSE reimburses up to €10,038

• Knee replacements from £10, 490 (€12,064); HSE reimburses up to €10,471

• Tonsillectomy from £2,900 (€3,335) ; HSE reimburses up to €3,173

• Carpal Tunnel, from £1,028 (€1,182); HSE reimburses up to €1,365

Based on Sterling/Euro conversion rate £1=€1.15

The patient also has to always pay his/her transport costs and hotel overnight costs, for which, in the Kingsbridge case, a special CBD rate is available in designated hotels

PDFORRA intervenes for its members

PDFORRA, the Permanent Defence Forces Representative Organisation, was as sharp as the clutch of canny politicians in spotting the potential of the Cross Border Directive.

Its rank and file members would not have the resources to fund the cost of private health insurance. They sometimes find themselves struggling with debilitating medical conditions as they take their place in the queue on long public health waiting lists.

So PDFORRA established its own Private Medical Assistance Scheme to help its members tap into the potential of the Cross Border Directive.

What is effectively the Defence Forces trade union has formed a special relationship with the Kingsbridge Hospital in Belfast. PDFORRA members are paying in a small sum to participate in what is effectively a top-up insurance scheme. They use CBD funding to access fast treatment across the border and any required top-up payment comes from the PDFORRA insurance scheme, a service provided by Cornmarket.

Image - PDFORRA has helped its members tap into the CBD

PDFORRA has helped its members tap into the CBD

According to Kingsbridge, to date over 100 members of PDFORRA have attended the Belfast hospital for successful medical procedures. The PDFORRA website features details of the scheme and it includes the testimonials of several members including Terry:

"I was in need of a hernia repair procedure and as I was on the public waiting list. I had no timeline as to when my operation would be carried out. I signed up for PMAS and within 6 months I had my hernia repair completed and back to my normal routine."

And Georgina:

"I joined the MAS scheme very early on as I thought it was a great initiative by PDFORRA. It turned out to be one of the best things I ever decided to sign up to."

Accessing services in mainland Europe

Northern Ireland and Kingsbridge Hospital in particular is attracting most of the CBD and budget. But some patients are going to other EU countries. HSE information from three years ago indicated that as many as one in five Irish CBD users were travelling to Poland for care.

The role of an Ireland-based Polish doctor and a Dublin-based Polish-born manager in the health sector is a significant influence in this factor. The users of the CBD service to travel for care to Poland are often Poles who have moved to work and live in Ireland or their friends and acquaintances who learn from them about the merits of the scheme.

A highly-significant element of the CBD is the subsidy/payment offered to patients is, at most, the going rate for the procedure in Ireland. If the actual cost is lower, then the refund is for the lower amount.

Because wages and other associated costs in the Irish health sector are higher than those of many EU member states, the cost of a procedure elsewhere can often be cheaper than in Ireland. This is definitely the case in eastern European countries, with a tradition of high-quality clinicians.

Image - The cost of a procedure elsewhere can often be cheaper than in Ireland

The cost of a procedure elsewhere can often be cheaper than in Ireland

The HSE slide show, used to explain how the CBD operates at public meetings and at discussions with interested parties, includes the stories of:

SR – Cleft Palate (Czech Republic)

• SR was diagnosed with a cleft palate pre-birth during the mother's ante-natal care

• Both parents were from Eastern Europe.

• The parents sourced corrective surgery in the Czech Republic and scheduled the intervention for a few days after the baby's birth.

• The maximum reimbursement rate for the surgery in Ireland was €10,241.

• The actual reimbursement value claimed was €993.54 being the cost of the surgery in the Czech Republic.

CD – Hip Replacement (France)

• Sought hip replacement in France.

• Had double hip replacement with ceramic implants.

• Irish reimbursement rate €10,931 per hip total €21,862 max reimbursement rate.

• Cost in France was €19,462 but was reimbursed €19,453 as the cost of the TV in the room was not reimbursable!

• When contacted 10 days post surgery, CD apologies for missing the call as she was hoovering and didn't hear the phone! The point being that 10 days later her life was back to normal – consider this against waiting list times.

An argument can be made that the millions of euro spent of the CBD might have a better long-term impact if used to build up the country's healthcare infrastructure

Trasna, based in Waterford, is one of several companies set up to provide an advisory and support role for individuals who want to use the Cross Border Directive to access treatment abroad.

Its founder, Martin O'Rourke, was a former chairman of BUPA Ireland and former deputy CEO of VHI. 

It has established working relationships with a number of service providers in Europe. It says on its website that it does not charge patients for its service but is financed by an administration fee, given by the hospital it uses. 

Trasna states on its website it can access hip replacement work in Norway for €10,000. This is €1,600 cheaper than the going rate at Belfast's Kingsbridge.

Northern Ireland - losing on the double

Northern Ireland is fertile ground for cross-border CBD customers because it is a relatively short drive rather than a flight away. Often the person seeking surgery is middle aged or elderly, may not have a passport, does not want to take a flight and is struggling with a debilitating condition.

For the Department of Health and the politicians and managers who oversee it, the Cross Border Directive is a no-brainer. It is a quick fix – it is a small but increasingly important release value for the growing public waiting lists.

The cost of each CBD procedure is, at most, the going rate in Ireland so it is, in crude terms, cost effective. Another important truth is access to the scheme is a person's right as a member of the European Union so it cannot be denied to citizens.

An argument can be made that the millions of euro spent of the CBD might have a better long-term impact if used to build up the country's healthcare infrastructure. But tell that to the person waiting two years for a hip replacement who can be offered a service up the road, over the border, which guarantees the life-altering procedure in two months.

Most of the consultants and other professionals working at the Kingsbridge Hospital in Belfast are NHS employees, working in local NHS hospitals. There are very few Northern Ireland based full-time private clinicians because there is no significant history of private health care, north of the border.

So the key personnel carrying out the procedures on the CBD patients, who have arrived in Northern Ireland from the Republic, are NHS staff who are working at the private hospital in their private time.

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They have fulfilled their NHS contractual obligations – Kingsbridge offers a second source of income. Some carry out CBD patient consultations on week days but the actual CBD surgical procedures at places like Kingsbridge usually take place at weekends, or in some cases, on Fridays.

This growing phenomenon of Cross Border Directive patient work, carried out in a private setting, may have some bearing on the capacity of Northern Ireland's NHS system to deal with its core patient group. Statistics produced last week confirmed that for many services, Northern Ireland has the UK's waiting lists.

The NHS lists problem is increasing while Northern Ireland's private practice component, still tiny compared to the Republic of Ireland, is growing.

Kingsbridge has actually explored the possibility of doing a double on the Cross-Border directive. As well as its Belfast private hospital, the company also owns a facility in Sligo, the old Garden Hill hospital, bought from the Mount Carmel group during the recession. 

Its CEO Mark Towey, in association with Mark Regan in Belfast examined the possibility of wooing Northern Ireland patients to Sligo and using the Cross Border Directive provisions - in this instance UK money - to fund procedures.

But the plan has hit the buffers, mainly for two reasons. In the Republic a referral from a GP is enough to get a patient up and running in seeking access to a consultant in another member state and to the HSE unit overseeing the scheme.

But in Northern Ireland to have engagement with the NHS-supervised Cross Border Directive, a person must have a consultant's/clinician's support. As outlined in relation to the CBD on the NHS website:

"...the letter provided by the EEA clinician must clearly state why the treatment is needed in your circumstances, and what the clinician considers to be a medically justifiable time period within which you should be treated. The clinician should support his statement by giving objective reasons."

Sometimes the waiting time to see a consultant/clinician in Northern Ireland can be two years or more. Sometimes, perfectly within their rights, those same consultants, in their private time are carrying out procedures on Republic of Ireland (RoI) CBD patients at places like Belfast's Kingsbridge Private Hospital.

The other undermining factor for a potential Northern Ireland run CBD scheme is the going-rate, the budget for a procedure allowed to patients, seeking treatment across the border or elsewhere.

Because the NI going rate is often significantly less than that of the RoI, the patient would have to make up a considerable shortfall. (Private hospitals in Dublin, Cork and Galway, where the key staff are sometimes consultants who also work in the public sector, charge approx €12,000 for a hip replacement – some thousands more than the NHS going rate and the budget of any Northern Ireland citizen, seeking to use the Cross Border Directive to travel south.)

These two factors explain why Kingsbridge has struggled to replicate the runaway CBD success of its Belfast model at its site in Sligo.

Image - For the Department of Health the Cross Border Directive is a no-brainer

For the Department of Health the Cross Border Directive is a no-brainer

So what will happen after Brexit?

As the Cross Border Directive is a creation of the EU and bearing in mind most of the Irish users are accessing services in Northern Ireland's private sector, a very obvious question is what will happen if and when the UK - Northern Ireland included - leaves the EU?

The good news for Republic of Ireland patients is the scheme is likely to continue and it expected to operate as it currently does.

As the Brexit negotiations gathered pace earlier in the year and worries about a hard Brexit increased, the British and Irish administrations increased their levels of contact and negotiation on several fronts, including health-related issues.

If the EU does leave the European Union, an arrangement already between Ireland and the UK, known as the Common Travel Area, will become more relevant. This series of arrangements and understandings operated long before the UK and Ireland joined the Brussels club in 1973. They allow free movement between citizens of the neighbouring islands, and reciprocal rights to work, enrol in educational institutions, access benefits etc.

Formal Memorandums of Understanding between the British and Irish administrations, addressing these provisions, will be put in place at the appropriate time after Brexit. They will include health provisions, including an interpretation of the Cross Border Directive as it currently operates. In practice this will commit Ireland to covering the cost, at specified levels, for treatment its citizens receive in the UK, Northern Ireland included.

There is another measure, an EU provision called the Treatment Abroad Scheme, which allows Irish citizens to avail of services in the public system of another member state, provided they have prior authorisation from the HSE to do so.

(I became the first Irish user to make use of this service when I accessed cancer treatment in Uppsala in 1998).


The CBD is proving to be a magic solution for those struggling with pain and caught in the queue of a long public waiting list

As the table below sets out, almost €13m has been spent of the Treatment Abroad Scheme so far this year, involving 108 procedures. 

In many cases highly complex surgical procedures are involved and the services are accessed in the UK. The Treatment Abroad Scheme budget also includes the cost of the Air Ambulance Service – it is a vital element when, for example, a patient is being rushed to a UK Centre of Excellence for vital organ replacement surgery.

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All the indications are that a version of the Treatment Abroad Scheme, involving Ireland and the UK will continue after Brexit. Irish patients will remain to access what are often life-saving or life-altering procedures in the UK, with the State picking up the cost, provided the service is recommended by an Irish clinician and has prior authorisation from the HSE.

There is one final element of the cross-border healthcare jig-saw and it provides a fascinating insight into the thought process of the likes of Leo Varadkar, Simon Coveney and Simon Harris and their influential advisers, including Martin Fraser, Brian Murphy, John Calinan, Jim D'Arcy and Eamon Molloy.

It involves the EHIC card - the European Health Insurance Card - that so many of us bring with us when travelling elsewhere in the European Union. 

This entitles the holder to access free health care, or reduced-cost care, when on holiday or during a short-term stay, generally seen as less than three months, in another EU member state. 

You apply to your local health office when seeking the card. It lasts for five years. Families who have had a mishap during a campsite holiday in France or those whose slipped and sprained a limb in Lanzarote know the value of the EHIC card.

Image - How will EHIC cards be issued after Brexit?

How will EHIC cards be issued after Brexit?

During the run-up to some of the crunch Brexit votes in Westminster, the Irish Government made it known that it was examining its responsibilities, as it saw them, under the Good Friday Agreement to the citizens of Northern Ireland.

The official policy in relation to this is now crystal clear. After the UK leaves the European Union, the Irish Government will put in place its version of the European Health Insurance Card (EHIC) for all Irish, EU and British citizens who are resident in Northern Ireland.

Dublin will commit to providing all 1.7 milliion of them EHIC-like cover when visiting an EU member state or European Economic Area country of Switzerland.

The estimated cost of this 'no strings attached' plan by the Irish Government is €5m - that figure is probably arrived at by using the statistics from the current EHIC costs run up by the RoI's citizens.

How the post-Brexit, special deal, Ireland-funded, Northern Ireland version of the EHIC cards will be issued has still to be worked out. So has a matter like whether the recipient might have to pay the health costs up front and seek reimbursement from Dublin.

But the initiative is an interesting example of the practical challenges created by Brexit.

Big picture conclusions

In the meantime, the big picture story is the growing popularity of the Cross-Border directive. As a result of the increase in demand, the HSE's unit in Kilkenny dealing with the scheme has been struggling to process claims for reimbursement. Extra staff are being hired and trained and there is an acknowledgement that a three month gap in having legitimate expenses refunded must be halved or better.

But the CBD is proving to be a magic solution for those struggling with pain and caught in the queue of a long public waiting list. 

Take the case of a pensioner in Donegal, Sligo, Monaghan, Cavan, Galway needing a hip replacement. Dublin, Galway and Belfast are equidistant. Public waiting list – two years, all going well. Cost of the work in an RoI private hospital - approximately €12k. Cost of the work in Belfast, using the CBD and paying the excess - €1500, including hospital excess, travel and accommodation charges.

In many parts of Kerry, minus their cataracts, pensioners will be seeing the stars afresh this Christmas and giving thanks for The Cross Border Directive. And in Belfast, Suresh Tharma and Ash Songra, the main shareholders in Kingsbridge Healthcare might also be raising a glass or visiting a car showroom.

The latest HSE reimbursement rates for procedures under the Cross Border Directive are available the websites below. This information provides the patient with a budget – the maximum amount refundable – if one gets work done abroad.

Inpatient treatment costs in Ireland - 'Admitted Patient Price List Summary (Inpatient)' (PDF, 1.39mb,32 pages).

Day case treatment costs in Ireland - 'Admitted Patient Price List Summary (Day case)' (PDF, 821kb,15 pages).