How can the Northern Irish healthcare system be fixed?

The health and social care system in Northern Ireland faces significant challenges: from long waiting times for appointments to declining numbers of GP practices. Additional resources and strengthened political will are essential for improving the system and health outcomes for the population.

There are continuing concerns about the performance of Northern Ireland’s health and social care system (Heenan and Appleby, 2017). Seven fundamental reviews of healthcare in the nation have been completed in just over 20 years.

A broad consensus on the key issues has emerged from these reviews. There is an over-abundance of – and excessive reliance on – hospital-provided care in Northern Ireland. The healthcare system requires more effective performance management, greater strategic workforce planning and changes to the level and period over which funding is provided to facilitate a more strategic approach to service planning and delivery.

The symptoms

The Northern Irish healthcare system is arguably as well funded as in other parts of the UK. But statistics on its performance are stark (O’Neill et al, 2021).

Both waiting list sizes and the waiting time for a first appointment in Northern Ireland are the worst in the UK. For example, in 2019, before the disruption of services caused by Covid-19, the number of people waiting over a year for a consultant-led outpatient appointment was 100 times greater in Northern Ireland than it was in England (allowing for differences in population size).

In December 2021, almost 85% of outpatient appointments breached the ministerial waiting time target of nine weeks, with over 52% of outpatients waiting more than a year to be seen. Further, 81.5% breached the 13-week waiting time target for admission for treatment, with almost 58% of patients waiting more than a year.

Of those waiting for a diagnostic test, almost 57% breached the target of nine weeks with over a third waiting more than 26 weeks (Department of Health, 2022).

Figure 1: Northern Ireland waiting time statistics, outpatient waiting times, quarter ending December 2021

Source: NISRA, 2022

These earlier problems were not the result of Covid-19 pressures, although the numbers waiting for outpatient appointments, diagnostic services and inpatient/day case admission continued their upward trend during the pandemic. For some specialties, such as rheumatology, these average waiting times can conceal much longer waits that can extend up to seven years, effectively amounting to a denial of service.

Outside hospitals, there is substantial evidence that GP services are also facing serious capacity problems. Demand in the community has risen due to population ageing and patients’ needs becoming more complex with rising multi-morbidities (the presence of two or more long-term health conditions).

Since 2014, the number of GP practices in Northern Ireland has actually declined by 8% and the average number of patients per practice grown by almost 14% (Department of Health, 2021).

Worryingly in terms of workforce and service planning – and given the centrality of primary care to the operation of the entire healthcare system – data on the number of GPs in Northern Ireland have not been available since 2003, when the new GP contract was introduced. (Full-time equivalent figures are produced for England.) In the absence of good data, it is hard to understand the current situation, let alone plan for a better one.

On a weekly basis, the media report stories of excessive delays for care, service crises and individual tragedies that are indicative – to paraphrase Sir Liam Donaldson’s assessment in 2014 – of a system with systemic problems throughout, where incidents of harm are distributed largely by chance both by location and type.

A recent pronouncement by a representative of the Royal College of General Practitioners that a telephone triage system adopted by GPs during the pandemic is ‘here to stay’ exemplifies the reactive and crisis-driven nature of change rather than one that is rationally planned and prepared for.

Diagnosis and treatment

So how do we fix this? A broad consensus on some of the fixes exists. The Donaldson and Bengoa reports, for example, echo the much earlier Hayes report of 2001 and set out a compelling case for rationalisation across the hospital sector. This would include the ten acute hospitals that currently serve a population of 1.8 million.

Rationalising services – and in particular elective services – would allow them to be delivered in a more efficient, safe and sustainable manner. It would increase throughput and allow economies of scale to be achieved.

Staff would also work in a safer and more supportive environment, where expertise could be acquired, training provided and a critical mass achieved that would avoid recourse to expensive locums and agency staff. Better working conditions such as these should make it easier to attract and retain staff and avoid expensive staff turnover costs.

With respect to workforce planning, we need data on the demand for and supply of effort. Here, planning models must reflect the multidisciplinary teams in which staff work, rather than the silos in which they train. They should also take account of evolving technology and work practices as well as training lead-times.

But as noted, information on the current situation is essential for future planning. For example, the current GP numbers could be estimated and compared with how many were trained to get a better understanding of how many more we need to train for the future.

Similarly, among consultants, we need to know how many ‘programmed activities’ – units of effort – are actually devoted to treating patients. This would improve understanding of how many are required for projected future needs. As with hospital rationalisation, this seems like a ‘no brainer’ and such information should be readily available for governance in any event.

In addition to how we use resources currently, there is undoubtedly a case for additional funding across the NHS to help fix historic underinvestment during the years of austerity. As noted in a recent Lancet Commission, significant sustained investment in our healthcare services is required. The perverse incentives caused by annual budgets should also be eradicated.

We need to value nurses, doctors, care assistants, social care staff and informal carers without whom the service would collapse. This needs to go beyond applause and manifest itself in real-term pay increases. This would have to come with an acceptance of the consequences for taxes or what other services the state can provide from current taxes (O’Neill et al, 2021).

All of this is largely agreed, so why are we not doing it? The answer is simple: these are political decisions and require political leadership. The hope for change – that successive fundamental reviews have helped to sustain – increasingly, one fears, has facilitated inertia and procrastination among those who lead the service.

Since powers were devolved to Northern Ireland’s legislative assembly, Stormont, in December 1999, it has been suspended on five occasions. The most recent crisis was in February 2022 when the First Minister resigned over the Northern Ireland Protocol. Only an impending election avoided another suspension.

Even when the Assembly has sat, its record in progressing change is far from stellar, as the above record shows. The number of reviews that have arrived at essentially the same conclusions – but produced limited responses – is perhaps indicative of a desire to delay rather than embrace change.

Perhaps in recognition of this, the review by Sir Liam Donaldson in 2014 (which set the stage for the review by Rafael Bengoa in 2016) called for local politicians to commit to the recommendations of an international panel in advance of their delivery with a view to circumventing the braking mechanism that local politics can exert on reform.

In a previous study, we noted that ‘all politicians are aware of the backlash that can be generated by hospital closures and in Northern Ireland, where there are proportionally six times as many as in the House of Commons, any closure would affect a lot of politicians’ (McGregor and O’Neill, 2014). In essence, politicians are unlikely to close a hospital – even if Northern Ireland would collectively benefit from rationalisation – for fear of losing crucial votes.

To make the necessary changes to the health service, Northern Ireland needs to fix its politics and/or how its politics interacts with the health service. In a democracy, this can be done by voting in politicians who serve the population’s interests and voting out those who don’t.

If this is a step too far for Northern Ireland, it may be necessary to take the health service out of the hands of the politicians and develop valid and transparent measures by which those who do lead it can be held to account for its performance.

If neither of these options are pursued, we need to be honest and accept that resources will be wasted, outcomes will be poorer and health disparities will be likely to widen.

Where can I find out more?

The right time, the right place: The Donaldson review of health and social care in Northern Ireland.

Securing a sustainable and fit-for-purpose UK health and care workforce: Ciaran O’Neill and colleagues explore the need for improved workforce planning in Northern Ireland’s healthcare system.