The fundamental principle underpinning the NHS, of healthcare free at the point of delivery has been eroded. Many have concluded that the system is broken, lurching from one crisis to the next, firefighting, unable to find an even keel. Prior to Covid-19, health and social care was in an all-too-familiar state of turmoil: stretched to its limits and struggling to cope with the seemingly intractable problems affecting almost every aspect of the system. Any remote hopes of a rapid recovery post-Covid-19 were dashed when the devolved institutions collapsed, and the North found itself once again in a political limbo.
This decline cannot be explained by the global pandemic and its myriad of consequences but is something that has been repeatedly predicted. Seven major reviews have highlighted the need for structural reform. Services need to be rationalised into fewer larger hospitals, alongside the development of regional specialist centres.
In 2016 the Bengoa Report noted that the stark options are to resist change and see services deteriorate to the point of collapse over time, or to embrace transformation and work to create a modern sustainable service. At the last election our political leaders followed the well-trodden path of on the one hand wholeheartedly supporting Bengoa’s recommendations. The public have been told ad nauseum of the need to “get Bengoa done” and “implement Bengoa”. Whilst on the other hand, politicians have resisted any proposed changes that might impact on service delivery in their own constituencies. Despite protestations to the contrary, we have been unable to move beyond parish pump politics, and health reform has not been progressed.
The statistics tell their own story. In the last financial year of 2021–22, the Department of Health accounted for 49% (£7 billion) of the Executive’s resource spending. By any measure performance is dire. Despite the highest spend per head of population of any region in the UK, the North has by far the worst outcomes. Prior to the pandemic, the number of people waiting to see a consultant was 100 times higher than in England. Over a third of the population is on a waiting list. More than a third of those waiting for an outpatient appointment with a consultant have been waiting at least two years. Waits of up to eight years to see a consultant are commonplace. In England a significant part of the Covid backlog has been addressed, with waits of more than two years to see a consultant virtually eliminated. Meanwhile here backlogs continue to grow. The last six months of cancer waiting times are the worst on record. A vacuum in relation to policy coupled with low levels of investment means we are at the bottom of the UK league table in relation to cancer outcomes. Despite the fact that they are markedly less ambitious here than in the rest of the UK, all elective care targets have been routinely breached since 2009.
Nurse’s pay here lags considerably behind the rest of the UK. In 2019 they held their first strike in a century to achieve pay parity. A key commitment in New Decade New Approach, was to address this issue, but to date the gap remains. There is a severe shortage of nursing staff in Northern Ireland, as the latest (31 December 2022) figures from the Department of Health illustrate, with 2,714 nursing vacancies in the HSC and a similar vacancy rate estimated in the independent or nursing home sector.
Since 2014, the number of GP practices has declined by 8% and the average number of patients per practice has grown by 14%. Repeated calls for additional investment in training and infrastructure were dismissed as unaffordable. The current solution of hiring expensive agency staff and expecting hard working staff to work even longer hours is not in the best interests of medical professionals and the public. In 2012/13, Health and Social Care spent approximately £69m on agency staff and by 2019/20 this had risen to £255m.
A recent report by the NI Fiscal Council on the sustainability of health care raised real concerns about significant inefficiencies in the current system. The average cost of patients admitted to hospital rose by 28 per cent in Northern Ireland between 2015/2016 and 2019/2020, compared to an 8 per cent increase in England over the same period. It highlighted significant issues with transparency, accountability, scrutiny and governance, but predictably it fell on deaf ears.
Following the Review of Public Administration in 2009, five integrated trusts have provided health and social services across Northern Ireland on a geographical basis and a sixth trust, the Ambulance Service operates on a regional basis. Whilst we have had multiple reviews focusing on how services should be configured, governance structures have attracted scant attention. Given that the system is on a cliff edge, isn’t it time to assess the extent to which these administrative bodies are fit for purpose?
Does a region with a population of 1.9 million really need multiple trusts and the extensive administration that goes with them? Six chief executives, six HR directors, six finance directors etc. Six boards with six chairpersons involving approximately 30 paid non-executive directors. Is it realistic to have a single health minister in charge of half of the devolved budget? Also in what other walk of life would the person in charge of a multi-billion pound operation need no relevant experience, no competence in that area?
Couldn’t we explore a model similar to NHS England, a body with day-to-day operational independence, headed by a Chief Executive? Or a model akin to the bank of England monetary committee, the BBC or the Policing Board. Whilst NHS England is not perfect, a study by the Health Foundation based on views of 11 former health secretaries in England noted that this model had depoliticised day to day decision-making. A whole raft of decisions that would have gone past ministers were just taken operationally, independently of politicians.
A single system could remove some of the bureaucratic barriers to change, drive improvement, ensure consistency and address a siloed mentality. Providing a clear line of accountability and addressing performance management could help to rebuild public confidence. At the very least, with a regional body, we would know where the buck stops. The public rightly expect to be able to hold decision-makers who oversee the health and social care system to account. Years of procrastination, complacency, and political cowardice have led us to this breaking point. Taking health out of the hands of politicians might finally enable the transformation and innovation that we so desperately need.
Addressing these challenges will not be easy but is not impossible. A ten-year plan which sets out the vision for health and social care and details of what services will be where and why would give reassurance to the public. We are currently witnessing the unplanned collapse of services rather than the long-promised transformation. If we are incapable of the radical change required then we must accept that health inequalities will widen, resources will be wasted, outcomes will be poorer, the staff exodus will continue and people will die prematurely.