How long must we wait?

Rebuilding any health system after Covid-19 will be difficult, but it could be an even tougher task in Northern Ireland. Deirdre Heenan and Mark Dayan assess the impact of the pandemic on an already beleaguered health system, and argue that support and goodwill for the NHS over the past months must be converted into the will to make major improvements.

Blog post

Published: 04/09/2020

At the beginning of June, Northern Irish health minister Robin Swann launched his Framework for Rebuilding Health and Social Care in Northern Ireland. Acknowledging that the health and social care system was in very serious difficulties long before the pandemic, he stressed that the virus had multiplied the challenges and pressures.

But that document is about the first steps to recovery from the immediate crisis. It is not a detailed and comprehensive strategy for addressing the longer-term problems that the virus exacerbated. It says relatively little about waiting lists, other than ordering trusts to create rolling three-month plans to increase the volume of treatment after historic slowdowns. The same is true for Northern Ireland’s many other fundamental issues: workforce planning, social care reform, technological advancements and the need to focus on prevention.

Starting behind

Prior to the virus, the health and social care system was in an all-too-familiar state of turmoil: stretched to its limits and struggling to cope with record levels of demand, soaring costs, and targets for A&E care, operations and cancer treatment being missed by more and more each month.

In 2016, the respected Spanish health care leader Rafael Bengoa had led a landmark report for Stormont, laying out an ambitious process of reform, where the health system would do more to help people stay well and avoid the need for so much hospital care. But we warned last year that the ambitious process had stalled after years of a lack of leadership.

The situation for planned care waits in particular was shocking relative to other UK countries: Northern Ireland was the only country in which waits of over a year were commonplace. Figures for June this year showed that the pandemic had made the situation worse. 175,000 people were waiting more than a year to see a consultant for the first time – up from 128,000 last June. As shown in the chart below, this is equivalent to nearly a tenth of the entire population.

People waiting for planned care per 1000 03/09/2020

Chart

Note:  

Northern Ireland counts inpatient waiting times from the decision to admit, rather than from referral

Source:  

Nuffield Trust analysis of data from the ONS, NHS England and the N.Ireland Department of Health

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People waiting more than one year per 1000 03/09/2020

Chart

Note:  

Northern Ireland counts inpatient waiting times from the decision to admit, rather than from referral

Source:  

Nuffield Trust analysis of data from the ONS, NHS England and the N.Ireland Department of Health

Read more

This is not unique: many countries across Europe cancelled planned operations by the thousand, and long waits soared in England as well (Scotland and Wales have yet to publish figures). While the total number waiting fell in England, this was largely due to GPs ceasing to refer people, and there can be no doubt that more people went without the care they needed.

Yet Northern Ireland’s huge backlog of people languishing without treatment meant that the slowdown during the pandemic – which saw fewer than half of the usual number of procedures happen – pushed huge numbers into the longest waits.

The health minister has conceded that these are just the tip of the iceberg, and that later figures reflecting the impact of Covid-19 will be “even more depressing”. Waiting lists this long result in increased disease, poor mental health and preventable deaths.

We need a plan of action

To date though, there has been no strategic and concerted response to the staggering differences in waiting times in Northern Ireland and the rest of the UK.

While real-terms spending on health and social care across the UK has stagnated since 2010, spending in Northern Ireland is still higher than the UK average. It is not entirely clear why Northern Ireland carries out a lower rate of elective care than elsewhere in the UK, although workforce problems, less pressure to perform, and the well-known tendency to split services across too many sites are likely candidates.

What is clear is that the crisis has made it worse. And while the English NHS has set a possibly over-ambitious goal for trusts to return to full speed from September for outpatients, the three-month plans produced by Northern Irish trusts seem to set a more leisurely pace. The September targets add up to fewer than 20,000 first outpatient appointments, for example – whereas on average nearly 40,000 outpatient waits were completed each month before the crisis.

We have seen a long overdue start made to the process of focusing planned care into particular centres to improve productivity. But this needs to happen in the context of a sustained focus on this issue, with a detailed strategy addressing issues of capacity; the scaling-up of elective care centres and the outsourcing of care to the private sector. This would be accompanied by indicative timescales, monitoring frameworks, performance metrics, data analysis and expected outcomes.

And if there has been only narrow progress in addressing the long-term problems with waiting times in health, there has been none addressing the significant issues with social care that were brought into sharp relief by the virus. How will they be dealt with? We can only guess.

The response to the pandemic has shown that the health and care system can be agile, responsive. Collaboration can address silos and fragmented service delivery. Decisions were taken at pace and entire hospitals were reconfigured. Undoubtedly, lessons have been learned, and the Framework acknowledges that good practice and innovations such as increased use of virtual clinics and telephone triages should be embedded into primary and secondary care.

These changes are welcome, and at their best develop some of the ideas that Bengoa recommended. But as his report suggested, progress will always be limited as long as unacceptable waiting times and poor social care hold back the system and the public’s trust in it.

The Framework sets out a proposed new management board to oversee the rebuilding of the health and social care system. But there is a risk that this becomes simply another bureaucratic layer in a system that we found in our research was already widely described by those who worked in it as complex, centralised and opaque.

Desperate times

In the aftermath of the largest pandemic for decades, rebuilding any health system will be onerous, let alone one with problems as deep-seated as Northern Ireland. Infection control measures will greatly slow productivity and impede progress, and it may not be realistic to expect significant improvements in 2020.

We cannot, however, tolerate any return to a system in perpetual crises with short-term sticking plaster solutions. Wringing our hands and repeatedly outlining the difficulties is not a sufficient response.

The global health care emergency witnessed an unprecedented outpouring of public support and goodwill towards the NHS. It is crucial to ensure that this goodwill is converted into the momentum and political will to make the required seismic changes. The challenges are gargantuan. After the virus, we desperately need a much better plan to address the fundamental issues and deliver a safe and sustainable system.

*This blog was also published in the Belfast Telegraph on 4 September.

Suggested citation

Heenan D and Dayan M (2020) How long must we wait?”, Nuffield Trust comment.

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