Radical surgery on waiting lists in Northern Ireland is long overdue

While waiting times have struggled across the UK in recent times, the situation is much worse in Northern Ireland. Is there a way to turn things around? Deirdre Heenan and Mark Dayan give the expert view.

Blog post

Published: 30/01/2020

Waiting lists have been a problem across the UK over the past decade, with each one struggling to meet targets for planned procedures. But they are at their worst, by far, in Northern Ireland.

As at March last year, approximately 1 in 12 people in England and Scotland were on an elective waiting list. However, in Northern Ireland the figure was about one in every five. 130,000 people in Northern Ireland have been left waiting a year for care to start. In England, with its much larger population, the figure is just 1,400.

Waits this long create real risks to patients and may result in increased disease and preventable deaths.

Northern Ireland’s politicians are now saying the right things. Both Arlene Foster and Michelle O'Neill specifically mentioned waiting lists as a priority in their speeches at the restoration of the Assembly at Stormont.

What might help

But what will it take to turn around a situation this bad? The good news is that there are lessons to learn from other countries. The bad news is that there is no quick fix.

It’s not as simple as just increasing the volume of operations to take more people off the front of the queue. In fact, a review of waves of reform in England found they worked better when they focused on speeding up the process, rather than just expanding capacity.

In 2005 John Appleby, then at the King’s Fund, did extensive research on what worked to drive down waits and keep them low, using in-depth interviews with clinicians and managers in nine hospitals.

First, there needed to be a sustained focus on the task of reducing waits – at organisational level and fed right down to individual consultants who can make an important difference. Politicians can start passing on these signals now.

Progress took time, and permanently fixing the situation was more difficult than just clearing the list once through a big drive only for it to re-emerge. One-off drives like this, based on paying for overtime, are expensive and may mean staff expect clearing waiting lists to only be a temporary – and lucrative – activity.

Successful managers used analysis and monitoring to spot exactly where delays were being caused by bottlenecks for individual patients. They remodelled how whole hospitals and the wider NHS system of referrals and transfers worked to sort such problems out.

These strategic ideas were supported by smaller measures: the careful management of beds, ensuring the full use of theatres, and making sure social and community care were operating at full potential to get people home and make space for the next patient. Our research found social care has been a neglected policy area in Northern Ireland, and addressing this may be part of the answer.

Another idea worth widely considering is splitting planned care and emergency care onto different sites, especially in areas of Northern Ireland like Belfast, where many hospitals are near one another. This is something the English NHS is backing in its Long Term Plan, because it can prevent the space for planned care from being overwhelmed by urgent patients at crunch periods. Along with other steps for greater efficiency, it would be compatible with the Northern Irish service’s plan for “elective care centres” and may be politically and financially easier than actually closing sites to centralise care.

However, there is probably a need for Northern Ireland to increase its capacity to provide planned care as well. The country provided about 22 admissions for procedures per 1,000 people in the last available quarter, compared to 27 in England – despite spending more. Operating at the limits of what staff and space can manage has created a cancellation rate exceeding one in 10, meaning patients go right back to waiting after resources may have been wasted.

Workforce issues, in particular the very serious shortage of nurses, will be the crucial first step to overcome. The promise of finally lifting pay to levels seen elsewhere in the UK should generate goodwill, and leaders should look to build on that by making investments in training and keeping staff in service – reversing a sometimes desperately short-term approach in the past.

We also need to look pragmatically at use of the private sector in Northern Ireland. The number of NHS patients treated privately has collapsed since a moratorium due to financial strain – from 50,000 outpatients in 2014/15 to just 15,000 last year. This suggests there is some spare capacity waiting to be brought back if new funding can be directed to tackling waiting lists.

Not easy but not impossible 

Fixing Northern Ireland’s waiting lists will not be easy – and doing this while revitalising the vital longer term reforms set out in 2016 will not be easy at all. But it can be done. In England and Scotland, waits of over a year were also commonplace until decisive changes in the late 2000s – indeed, huge progress took place in Northern Ireland for areas like hip replacements. Across the border, the Republic of Ireland has finally started to have some success in improving its poor performance, at least for inpatients. Northern Ireland’s leaders are right to promise change, and the public should hold them to it.

Suggested citation

Heenan D and Dayan M (2020) “Radical surgery on waiting lists in Northern Ireland is long overdue”, Nuffield Trust comment.