Paul Robinson - CAWT Director General - Chief Executive Officer NEHB
CAWT is the acronym for Cooperation and Working Together, a cross-border health care initiative initiated in 1992 with the signing of the “Ballyconnell Agreement” between the NorthEastern and North Western Health Boards in the South of Ireland and the Southern and Western Health and Social Services Boards in Northern Ireland. The CAWT territory embraces the whole of the land boundary between the South of Ireland and Northern Ireland, accounts for twenty five percent of the total area of Ireland and has a population of over one million.
Its conception arose from a mutual recognition that, in addition to possessing a common demographic profile, the region in both jurisdictions shared specific problems, including high levels of poverty, isolation and peripherality. Within health and social care, it was felt that these would be best tackled through identifying and exploiting opportunities to work together in order to improve the health and social well being of the border populations.
Building on Foundations
In assessing progress to date it is important to realise that less than fifteen years ago cross border co-operation in health and social care on the island of Ireland was almost non-existent. The necessary facilitating structures for such work were not present and key personnel on the two sides of the border had virtually no contact with one another.
Since then much has been achieved. CAWT is not a policymaking organisation, which is politically directed, but its evolution has provided a crucial framework and support for health and social care professionals on both sides of the border. The strength and indeed the success of CAWTis based on a very real partnership between the four Health Boards and the commitment of their staff to cross-border working.
It would be impossible to detail in this short article the range of projects, training events, conferences and information exchanges undertaken, but success stories in Acute Care have included the development of cross-border dermatology services1 which benefited patients in Monaghan, Dundalk, Newry and Armagh; renal dialysis services delivered in Newry for patients across the border in County Louth; major initiatives in Altnagelvin and Letterkenny Hospitals in relation to cardiac catheterisation, oral and maxillo facial surgery and neo-natal intensive care services.
Within Primary Care, the project “Developing Primary Care Across Communities and Borders” brought together GP Practices on both sides of the border and achieved much in relation to building networks, sharing information and breaking down barriers.
Within Social Care, the key research project “Community Childhood AccidentPrevention Project”2, addressed the high level of accidents amongst children under five living in areas of deprivation. Projects such as “Parenting Initiatives in the Community” and “Protecting Children with a Disability” also developed very specific services on the ground. The work spanned the border, actively involving parents, teachers and communities in cross-border groups to examine common needs and to identify ways of working together.
Establishing Strategic Direction
CAWT was independently evaluated in 2000 by the Centre for Cross-border Studies3, who supported and verified its work.
CAWT was also featured in the all Ireland study “Cross-Border Co-operation in Health Services”4, carried out by Dr. Jim Jamison et. al., who noted that “a great deal has also been achieved by CAWT in terms of improved relationships.... attitudes to CAWT are generally very positive and there is optimism about future potential.”
In the recently published review of acute hospitals in Northern Ireland5, chaired by Dr. Maurice Hayes, there was again specific mention of CAWT. The review also stressed the need for a cross-border dimension to service reviews in both jurisdictions and recommended that health authorities along the border develop joint planning systems.
The establishment under the Good Friday Agreement of the North-South Ministerial Council has in turn provided a significantly greater focus, momentum and authority in the field of health through co-operation and joint action. Work is being taken forward on a structured basis by both Departments in conjunction with local agencies such as CAWT.
Specific cross-border projects are being initiated and CAWTis well placed to act as co-ordinator for several of these, including the development of a first responder scheme, and the establishment of community emergency planning forums.
The above reports and the existing climate of political and organisational change have had a major influence in shaping CAWT’s second Strategic Plan (2001 - 2004), which takes account of the North-South Ministerial Council and is reflective of the strategic plans of both national Departments of Health and the four regional Health Boards.
Further Service Developments
Current initiatives being taken forward by CAWT under its strategic plan include the establishment of cross-border GP out-of-hours (OOH) services. In June 2001, CAWT commissioned the universities of Ulster and Galway to conduct a feasibility study to look at the operational and strategic issues to be considered before cross-border OOH co-operation could take place. The study shows that approximately 70,000 people along the length of the border are closer to GP OOH services in the opposite jurisdiction and that approximately 70 per cent of these people live in isolated regions which can be classed as socially deprived.
CAWT is now exploring the possibility of piloting a cross border service in two identified population areas in the border region. From a patient’s perspective, this effectively eliminates the border from GP OOH provision. Its localitybased approach to needs assessment and care delivery might also be seen as a first stage in the wider development of improving access to other services. The increasing importance of population needs assessment in health care planning led CAWT to commission the production of a CAWT Population Health Profile. Whereas in the past each Health Board has held data on its own inhabitants, for the first time comprehensive health and social care information is now available on CAWT as a discrete region. The wealth of information contained in the report enables theidentification of issues, which are common throughout the region and concludes that this is “information for action”. As such, the Health Profile will help inform and direct CAWT’s future efforts and is one of its most significant achievements.
Benefits to patients on both sides of the border are the outcomes of an emerging strategic partnership between Monaghan and Craigavon Hospitals in relation to cardiac catheterisation and general surgery. Resulting improvements include enhanced local access and shorter waiting lists while a shared cardiac catheterisation provision enables the retention of cardiology services at regional level for both populations.
The strategic plan contains a range of other detailed service developments. These include a communications strategy for CAWT and the development of a comprehensive web site. Work is alsoplanned on accident prevention, health impact assessment, diabetes, cognitive therapy training, cross border fostering protocols and cardiac rehabilitation, as well as the development of a range of acute services.
The European Agenda
CAWT is now in the process of actively developing links with cross-border areas within other parts of Europe, looking at issues beyond the constraints of Ireland, North and South, to a common agenda in a wider European context.
A successful “Connecting with Europe” conference was held in October 2001, and was opened by both Ministers DeBrún and Moffatt. As a result, significant connections have been made with the Meuse-Rhine region. In addition, CAWT has been presented to HOPE, the Standing Committee of the Hospitals of the European Union, and is now a member of the working party currently drawing up inventories of hospital based crossborder co-operation throughout Europe.
I have sought in this article to give an overview of CAWT and its achievements, but in a nutshell the message underpinning and driving its work is simply that “illness recognises no borders.” The obvious corollary of this being “nor should we,” when as planners and providers of health care, such a principle might benefit our populations.
Based upon humanitarian concerns, I believe that this ethos of CAWT’s offers the people it serves, more benefits than can be attained by the health boards working in isolation. In fact, as I hope the examples I have given demonstrate, we have much to gain from practical co-operation.
1 Laying Foundations: Cross Border co-operation in Health
Hayes A., Birrell D. and Gray A. M., University of Ulster
2 Community Childhood Accident Prevention Project: Co-operation
and Working Together
Mullan C and Smithson R.
3 From Concept to Realisation: An Evaluation of CAWT
Centre for Cross Border Studies
4 Cross-Border co-operation in Health Services in Ireland
Jamison et al
5 Acute Hospitals Review Group Report
Dr Maurice Hayes, 2001