Stories
Part of John Hume’s greatness was his empathy with the people he grew up with in Derry. He gave away his Nobel Prize money. He established the credit union in his hometown.
In a way the trait is a very Derry thing. Nell Mc Cafferty, Bishop Edward Daly, Eamonn McCann, Martin McGuinness and Dana Rosemary Scallon all had versions of it.
Add to that line-up Damien Quigley. If Ireland had an Honours List system, he would be entitled to recognition. But he is the (almost) unknown soldier who has done life-changing work for his fellow members of the Defence Forces.
He is the key mover in an extraordinary project that would bring a smile to the face of John Hume and to probably the most impressive of European Commission presidents, Jacques Delors.
There is a Hume dimension and a Delors dimension in Damien Quigley’s story.
A native of Derry city, Damien joined the Irish Defence Forces in 1988. He became national support officer with its representative organisation, PDFORRA, fifteen years ago.
He quickly became conscious of the wear and tear effects that work and life outside work were having on the health of his fellow soldiers, sailors and air crew. He saw lots of them with limps and strains and pains and aches being discharged from service. Forced to retire early, simply because they hadn’t the quality of health to allow them to continue working.
They are not paid enough to allow them to subscribe to what is increasingly expensive private health insurance. Instead, they are dependent on the state’s public health system, with its long waiting lists.
Damien’s hobby-horse speech at PDFORRA events was about the absence of proper health provisions for his fellow members of the Defence Force.
He chased down the possibility of developing a private insurance group scheme, similar to the ones set up by gardai, nurses and teachers. But when the health risk factors, financial resources available to potential members and likely costs were listed, no viable proposal emerged.
But Damien’s obsession was rewarded with a miracle from left field.
He heard about the Cross Border Directive, an EU measure designed to allow citizens access to health services in other member states.
Damien began to explore if members of the Defence Forces, unable to access badly needed procedures in the clogged up public health system of the state they serve, might access care in another jurisdiction and have it paid for by the HSE.
It seemed like a perfect, instant solution. But immediately Damien wondered if it was too good to be true. So, he stepped up his research.
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The Cross Border Directive became active in Ireland in June 2014. It was 2018 before Damien and PDFORRA were satisfied they had worked up a version to serve their members.
On legal advice, they set up a separate company within PDFORRA to oversee the scheme. It is called PMAS – the PDFORRA Medical Assistance Scheme.
Damien was given permission by his Army bosses and the Department of Defence to devote his working time to overseeing the project.
He knew that users of the Cross Border Directive routinely have to pay a top-up to cover the gap between the HSE reimbursement costs for a procedure and the hospital, accommodation and travel charges. So PDFORRA set aside €150,000 seed capital to get the project underway.
The organisation then went to its members, urging them to sign up for the scheme. When setting up the credit union in Derry John Hume had a principle of making it accessible for ordinary people. Damien and his colleagues did the same with their Medical Assistance model. They fixed the membership cost at €1 euro a week and it has remained at that level since.
There are currently around 7,000 enlisted members of the Defence Forces. Around 6,000 of them are in PDFORRA. Over half the PDFORRA cohort, 3,000, have signed up to Damien Quigley’s scheme.
The location they identified to deliver the service is up the road, over the border, in Northern Ireland’s private health care sector.
To date 312 members have made practical use of the scheme. Almost half of them for specialist consultations but 170 for surgeries – operations to fix damaged knees, hips, shoulders, ankles, wrists. There have been cataracts, hernias, ENT work to repair broken septums. General surgeries.
In many cases the care recipients were attempting to continue working through injuries that occurred while on the job. Some involved individuals who were facing medical discharge because of problems that were not being addressed by the state’s misfiring public health system.
It is a rule of the scheme that the patient must pay the full costs in the health centre and then seek reimbursement from the HSE. The PDFORRA run scheme has an arrangement in place with its credit union, ANSAC (Army Naval Service Air Corps). Participants can borrow the money from the credit union and then replay the loan when the HSE reimbursement comes through.
Because he is dealing in ‘bulk business’ Damien has been able to negotiate discounted prices with the service providers. The going rate for knee replacement surgery can be £10,000 plus; with hip replacement a charge of £13,000 is common.
PDFORRA routinely manages to strike significantly discounted rates, keeping charges in line with the reimbursement amounts the HSE provides. Membership charges and the €150,000 seed capital provide the resources to cover any top-up charges.
On its website page (pdforramas.ie) PMAS has a Testimonials section, where members give their views.
Terry says
“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 six months I had my hernia repaired complete and am back to my normal routine.”
Dean says
“PMAS is an excellent scheme to get Quality Treatment quicker than the normal patient pathway. For members of PDFORRA it is only €1 a week. It’s amazing.’
Georgina states
“I joined the PMAS 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.”
Kieran tells
“I heard of the Cross Border Medical Scheme through a work colleague. With the public system I would have been looking at a minimum of four years before getting my knee surgery.”
The work of Damien and PMAS is be ongoing. His full-time job now is to run the scheme. He has probably a decade of service left.
A lot of his time is spent haggling about prices with the centres in Northern Ireland providing a service. But if the rate becomes an insurmountable problem, Damien is open to exploring the opportunities in mainland Europe countries where the travel and accommodation factors are more complex but where hospital costs may be cheaper.
At present the scheme is confined to PDFORRA members who are serving in the Defence Forces. The possibility of extending it to partners/children might in time be explored.
But right now, this story is an awesome example of how a soldier and his colleagues helping with the scheme are doing additional service to the state they serve, when its health system is unable to provide them with the care they deserve.
They have not found a magic money tree. Their secret is they have discovered the section of the state apparatus that pays the bills for the care another section of the state system cannot provide in a timely way.
The Kerry and Cork cross border travellers
At the opposite end of the country from Damien Quigley’s hometown of Derry, three canny observers took stock of how the Cross Border Directive might be harnessed to suit their purposes.
The Healy-Rae brothers, Michael and Danny, are from Kerry and the clan is in several businesses, politics included. Michael Collins is also an Independent TD but, strictly speaking, not a rival to the Healy-Raes because he represents the nearby Cork South-West constituency.
Significant numbers of residents in the two rural constituencies don’t have private health insurance. They are depending for health care on the state system. Many of them are medical cardholders. And while TDs routinely seek to help their constituents negotiate a path through lengthy waiting lists, supply does not satisfy demand.
The three TDs quickly grasped the potential of the Cross Border Directive. They identified a private hospital in South Belfast, Kingsbridge, as a possible source for their business and soon a structure was in place to address the health problems of hundreds of Cork and Kerry patients.
Ads were placed in local newspapers, seeking candidates for the new service. Buses were organised to transport the patients to and from Belfast. Deals were struck with hoteliers including Howard Hastings, owner of Belfast’s Europa Hotel, to provided discounted overnight accommodation for the travellers when necessary.
And suddenly the corridors of Belfast’s Kingsbridge Private Hospital were filled with Cork and Kerry accents.
Much of the work involved hips, knees and cataracts. As with the recipients in Damien Quigley’s PDFORRA scheme, the patients from Kerry and Cork had been dealing with painful limbs or poor eyesight for years, holding out to make it to the top of the waiting list queue.
The story of the flow of southern patients to Northern Ireland private hospitals, availing of the Cross Border Directive scheme, is one of many barely understood truths about the Irish health service.
The Directive offers Irish patients an opportunity to access care in all EU and EEA (Iceland, Liechenstein and Norway) countries. In 2020, 90 per cent of all HSE reimbursements – 7,845 of the 8,744 cases were for care got in the UK.
Some 98 per cent of those treatments were delivered in Northern Ireland.
That means 7,500 HSE reimbursements for private hospital care in Northern Ireland in 2020.
A large percentage of them were outpatient and day cases, of which 72 per cent were ophthalmology and orthopaedic treatments.
Since the scheme was introduced in June 2014, consistently the bulk of the traffic has involved patients going no further than over the border.
Kingsbridge Private Hospital in South Belfast has been the main beneficiary of that business.
The nearby Ulster Independent Clinic of Belfast’s Stranmillis Road is also a player.
The Cathedral Eye Clinic on Academy Street in central Belfast, targets the cross-border cataract business.
The North West Independent Clinic in Co. Derry also saw potential in the Cross Border Directive market. In July the Kingsbridge group purchased it.
Some of the work in Northern Ireland is carried out by consultants who work full-time in the private sector.
But others who are employed in NHS hospitals are also involved. They work their full complement of hours in accordance with their NHS contracts and in their private time they earn additional revenue in the private sector.
Patients arriving from the south know the level of reimbursement the HSE is prepared to pay for each procedure. If this does not match the charges of the Northern Ireland private hospital, the patient must meet the shortfall.
Location is an obvious bonus for the Northern Ireland centres. They are accessible, even for clients from Kerry and Cork at the opposite end of the island. But price has become a factor in recent times.
The SurgeryNow agency, seeks to persuade Irish patients to travel to mainland Europe centres in places like Spain. On its website it urges potential customers to ‘save thousands compared to Northern Ireland.’
The Irish solution to a Brexit related health problem
When a majority of UK voters decided they wanted to leave the European Union, it seemed southern patients were going to lose the option of accessing care over the border. Northern Ireland’s private hospitals had good reason to worry the bonanza created by southern patients was coming to an end.
But the authorities in Dublin were aware of the popularity of the scheme. They recognised it was acting as a release valve for pressures created by lengthy hospital waiting lists.
Fianna Fáil Carlow-Kilkenny TD, John McGuinness, twigged the possible implications of Brexit. He raised the issue in the Dáil.
In a written response of January 13th, 2021, Health Minister, Stephen Donnelly confirmed the government had moved to introduce a temporary measure – the Northern Ireland Planned Healthcare Scheme.
It would operate for 12 months and would replicate the service provided by the Cross-Border Directive.
In effect, it was an Irish solution to a Brexit problem.
For the government it meant that TDs including the Kerry Healy Raes and Michael Collins from Cork South-West would not be on its case in the Dail, lamenting the demise of a popular and novel scheme.
Below is the latest HSE-provided information, illustrating how, despite the travel restrictions imposed by Covid-19, patients continued to travel to Northern Ireland for care during the first half of 2021.
Table I provides the details for Outpatient activity.
Orthopaedics was the busiest sector during quarters 1 and 2, almost 400 cases. Ophthalmology (cataracts) came next – 265.
Table 2 shows the medical procedures approved for reimbursement on a Day Case basis. Some 238 ophthalmic procedures in the opening quarter of the year and 54 more in the second quarter. Some 38 orthopaedic procedures in QI and a further 9 in Q2.
Table 3 lists the approved applications for reimbursement in relation to inpatient procedures in Northern Ireland. In this instance orthopaedic work (hips, knees, shoulders) dominates – 184 in Q1 and 63 in Q2.
How Northern Ireland citizens were squeezed
Spare a thought for the 1.9 million citizens of Northern Ireland. The case can be made that they are getting the worst deal of all on the health care front.
As with all areas of the United Kingdom, Northern Ireland puts its trust in the National Health Service with access based on need and service free at the point of delivery.
Almost 50 per cent of residents south of the border have private health insurance – more than 10 times the Northern Ireland rate.
Compared to Wales, England and Scotland, Stormont presides over the UK’s longest NHS waiting lists: 335,000 people hanging on for a first consultant-led appointment, almost 190,000 of them waiting longer than a year.
In Northern Ireland’s Southern Trust area, the longest wait for a urology appointment is seven years. Some people are waiting more than five years for orthopaedic and general surgery; some are waiting more than three years for a pain management appointment.
Add to the mix the Brexit and the island of Ireland factors and Northern Ireland’s grievance deepens. Its private hospital workforce includes NHS personnel treating southern Cross Border Directive patients in their spare time.
And Northern Ireland citizens, many of them in pain, can only look on helplessly. Because the UK has left the EU, themselves included, unlike their southern counterparts, they have no entitlement to the EU-originated Cross Border Directive scheme that would allow them get care outside of Northern Ireland.
But Northern Ireland’s Health Minister, Robin Swann, helped by his advisors, is no slouch. In June 2021 when the headlines were dominated by discussions about DUP heaves and marching season tensions, Northern Ireland’s Department of Health published a news release that got little publicity.
Robin Swann announced a “new limited version of the Cross Border Healthcare Directive for the Republic of Ireland for a 12-month period from I July 2021.”
The Republic of Ireland Reimbursement Scheme “will allow patients to seek and pay for routinely commissioned treatment in the private sector and have the costs, up to the cost of the treatment to the HSC in Northern Ireland reimbursed.”
Let’s work that one out. We could have Healy-Rae and Michael Collins-arranged buses, heading North, meeting Robin Swann-sponsored buses on the MI heading south.
Kerry and Cork patients going to Belfast to get their hips or cataracts fixed, waving at Northern Ireland travellers en route to the Blackrock Clinic or the Mater, Vincent’s and the Beacon.
Is that mad, Ted?
One final question
There is one intriguing question about the Cross Border Directive. To date the state has forked out €50 million reimbursing Irish patients who have travelled out of the country for care they have not been able to access at home, because of the long waiting lists in public health system.
Most of that money has been paid to Northern Ireland’s private hospitals, mainly the Kingsbridge Hospital outside Belfast.
Have the owners and managers of Ireland’s private hospitals ever considered taking a legal challenge at EU level about the fairness of the Cross Border Directive?
