A S THE UNITED KINGDOM prepares to slip its European moorings, the ties that bind it together are also under strain. In Northern Ireland, which (like Scotland) voted to remain, there is often talk that a “hard Brexit” could even build new momentum for a united Ireland. One reason for doubting this, however, can be summed up in a word: health.

The 1.8m people of Northern Ireland enjoy free access to the British taxpayer-funded National Health Service ( NHS ). The Republic of Ireland’s 4.8m residents have to make do with something less appealing. “I know people up north whose life’s ambition is to see a united Ireland, and yet they worry when they see the health service we have down here,” says Louise O’Reilly, an MP in Dublin and health spokesperson for the all-island Sinn Fein party.

Ireland’s relatively high spending on health care—the seventh highest in the OECD , at $5,500 per head in 2017—is not matched by the level of service. In theory, public hospital care is free, but waiting lists for diagnostic procedures and publicly funded specialists can stretch for months, even years. An over-reliance on expensive hospital treatment, rather than care in GP clinics, has contributed to a chronic shortage of beds. On any given day, hundreds of patients will be waiting on trolleys in hospital corridors, sometimes for more than 24 hours, hoping for a proper bed. Ireland’s minority government is well aware that, along with the acute housing shortage, health is the issue on which they are most vulnerable.

Unlike their UK counterparts, some 60% of Irish people, mostly those who are not very old or very poor, have to pay up front in cash for primary health care: a single GP visit typically costs between €50 and €60 ($60-$68). The state only pays for medicines above a monthly threshold of €134.

Junior doctors and nurses battle with long hours, stress and inadequate equipment in overcrowded and dingy old buildings. Many choose to take their training abroad. Meanwhile, a planned new National Children’s Hospital, originally billed at a hefty €650m, has seen its projected cost balloon to €1.73bn. In terms of cost per bed, an estimated €3.7m and climbing, it would be by far the most expensive hospital in the world.

Experts blame much of the dysfunction on poor and piecemeal long-term planning, inadequate budget control and Ireland’s “two tier” public-private health system. In Ireland, unlike in most other EU countries, most specialists employed in publicly funded hospitals, already well paid by the state, are allowed to dedicate a portion of their time (typically 20%, though there is in practice little supervision) to private patients. These patients are often in the same public hospital and using publicly provided facilities. As a new EU country report noted last month, this “creates perverse incentives in publicly funded hospitals, where preferential treatment of privately insured patients adds to doctors’ private revenues”.

Róisín Shortall, a former junior health minister and joint leader of the centre-left Social Democrat party, notes that many worried families pay for no-frills health insurance (at an average annual cost of €1,850 in 2017), just to be able to skip lengthy queues. “Between 46% and 47% of Irish people are on private health insurance, which is by far the highest rate in Europe,” she says. Yet only 13% of the total Irish spend on health comes from private insurance, leading to the charge that the private sector is piggy-backing on the public one.

Many Irish people are familiar with and envious of the UK ’s NHS and in 2017 a cross-party committee of MP s voted unanimously in favour of Sláintecare (“Sláinte” means “health” in Irish), a detailed plan to introduce free and improved care at all levels of treatment. One key recommendation was the phasing out of private practice in public hospitals.

The government of prime minister Leo Varadkar, himself a doctor and former health minister, has said that it accepts the plan. In practice, though, it has done little to advance it. Ms Shortall says implementing the plan would require a €7bn ring-fenced investment over ten years. The government has so far voted it only €20m.

Diarmaid Ferriter, a social historian at University College Dublin, says that resistance to reform comes partly from free-market ideology (the Republic throughout its history has always been ruled by alternating centre-right parties, never left-wing ones) and partly from the insurance industry and senior doctors. “In Ireland in the 1940s private medical practitioners were worried about a reduction in their income from what they saw as “socialised medicine”, and they brought the Catholic church on board, saying that if the state extended its reach it might start looking at contraception and things like that,” he says. “The church has declined in influence, but the power of the consultants has not.”