Political deadlock and top-down approach frustrating efforts to improve health and social care in Northern Ireland

A new report from the Nuffield Trust looks at which factors are helping or hindering change in Northern Ireland.

Press release

Published: 10/07/2019

A political vacuum and a culture of centralisation are impeding reform of the health and care system in Northern Ireland, a new report from the independent think-tank the Nuffield Trust finds today.

Three years after Rafael Bengoa’s blueprint for improving the country’s health service, the report argues that although leaders in the service are committed to change, a lack of political leadership is blocking progress. It is also obstructing efforts to improve poor waiting times, on which Northern Ireland is already significantly the worst performer in the UK.

The report, Change or collapse: Lessons from the drive to reform health and social care in Northern Ireland, looks at which factors are helping or hindering change, and is based on interviews with health service leaders in Northern Ireland as well as outside experts and clinicians. It acknowledges that although the civil service is doing its best to provide leadership in difficult times, the collapse of power-sharing is exacerbating already chronic problems in taking difficult decisions.

It nonetheless reports a culture of centralisation and tight command and control at the heart of the health system, with both interviewees and academic literature suggesting such a top-down approach is not the way to make complicated reforms happen. Alongside the political unwillingness to take difficult decisions, it has created a bunker mentality discouraging openness about where the problems are.

A lack of ambition is also getting in the way of tackling waiting times. The report finds that a patient in Northern Ireland is nearly 50 times as likely to be waiting over a year for care than one in Wales, which is the next worst performer. It also argues that Northern Ireland is lagging behind on social care, despite being the only area of the UK with an integrated social care system. It is the only UK country to have not refined legislation underpinning social care in recent years.

The report also finds that historical failings in workforce planning for the health service in Northern Ireland are still prevalent, resulting in a shortage of important staff groups and a costly reliance on temporary workers. This is proving to be another significant stumbling block to achieving successful reform.

The report also provides lessons and possible warnings for other countries in the UK. With recent policies in England and Scotland emphasising clinical outcomes and preventive care over rapid access to services, the situation in Northern Ireland shows how bad waiting times can get in an NHS system if focus is lost.

Report co-author Mark Dayan, Policy Analyst at the Nuffield Trust, said:

“There’s no doubt that the people we spoke to, from staff at the front line to top officials, were often genuinely committed to changing to a health service that does a better job keeping people well. But this is colliding with a centralised culture that is exactly what you don’t need for a process of experimentation and working out new ideas. To keep on pushing from the top risks making things worse.

“Meanwhile the lack of political leadership makes difficult decisions hard to defend either morally or legally. We’re used to hearing Scottish and English healthcare leaders complaining about politics interfering in the NHS. But without elected leaders, it turns out things grind to a halt because officials don’t have the legitimacy to make tough calls.”

Report co-author Professor Deirdre Heenan, Senior Associate of the Nuffield Trust, said:

“The spiralling waiting lists in Northern Ireland represent a major breach of public trust in the NHS. Longer waiting times can be deeply distressing for patients and their families and make no economic sense.

“The equivalent of one person in five is on a waiting list in Northern Ireland, with more than 120,000 people waiting over a year for treatment. A citizen of Northern Ireland is more than 3,000 times as likely as a citizen of England to have been waiting more than a year for healthcare. How bad does it have to get before urgent action is taken?”

Notes to editors

  1. The Nuffield Trust held an event in Belfast in 2018 in which attendees explored four themes – politics, leadership, workforce and innovations at the front line. A series of interviews was then conducted through the course of 2018 with leaders within the system, outside experts and clinicians. Quantitative analysis around finance, workforce and waiting times was separately carried out.
  2. The report is the second in a Nuffield Trust series looking at what UK health systems can learn from one another, following Learning from Scotland’s NHS in 2017.