Notwithstanding the hugely successful vaccine rollout programme, Northern Ireland’s health system is straining at the seams. The waiting list for planned admission to hospital or a first outpatient appointment has reached almost 450,000, equivalent to almost a quarter of the population. In England, where services have been very hit hard by the pandemic, the waiting list is equivalent to just 9% of the population.
Shockingly, most of those waiting in Northern Ireland – 57% – have now been waiting for over a year, something that was supposed to be entirely eliminated by now. This rises to more than 60% of those whose needs require actual admission to hospital. In England, where concern about waits spiralling out of control is widespread, fewer than one in ten have waited this long.
The global pandemic has increased the pressure on waiting times everywhere, but the grim truth is that they have been almost this bad in Northern Ireland for several years. In a number of specialisms such orthopaedics, neurology and rheumatology, typical waiting times involve to five or six years, for an initial consultation for *urgent* referrals followed by additional years of waiting for treatment. To all intents and purposes these specialisms are closed to new patients. The Human Rights Commission is backing a landmark legal case for one patient forced to go private and another in their fifth year on a waiting list.
Waiting times here have been lagging behind for more than two decades. There was some success in decreasing the number waiting in the mid-2000s, but Northern Ireland never matched England or Scotland in making one-year waits almost unheard of during this period. These gains were then lost as the system spiralled out of control in the last decade.
Apart from the impact on patients, the situation adds pressure on already over-stretched clinicians and breaches trust with the public. Staff are doing the best that they can, but they must be supported by better systems and policies.
Turning around a problem on this scale will not be easy. Research on tackling waiting lists shows they are a complex issue with no one-size-fits-all solution. Policies and strategies have had limited success and generally improvements have proved difficult to sustain. Waiting lists of this magnitude are not simply a backlog which could be cleared with one big push. They are a symptom of a system that is struggling to cope – because it is not providing enough care to keep up with people’s needs, because it is managing and prioritizing badly, or both.
Resources are tight but should not be a binding constraint. Northern Ireland spent more on health care per head in 2019/20 than any other UK country – £2,489 compared to £2,310 in England. This may be justified by higher need, but studies by us, the University of Stirling and others suggest that an area of England with similarly higher need would typically spend about the same.
The lack of a multi-year budget is also a constraint only insofar as Stormont makes it one. The English health service nearly always ends each year with a different sum than it expected, yet it writes multi-year plans based on understandings with wider government and assumptions.
To date the Department of Health have produced no plans to deal with this steadily worsening crisis. Tackling waiting lists was identified as a priority in the New Decade, New Approach deal to restore devolution in January 2020, but the arrival of the pandemic meant that the thorny issue of waiting lists were once again sidelined.
Systemic reform of health and social care in Northern Ireland has been repeatedly delayed. Seven major reviews in the last two decades pointed in the same direction of travel: rationalisation of services into fewer, larger hospitals, regional specialist centres and a focus on prevention. Whilst there is political consensus that this reform is essential nobody actually wants to grasp the nettle, especially if it sounds the death knell for smaller hospitals. The public deserve better than empty platitudes and wringing of hands when the latest quarterly figures are published. No one is saying that this will be easy but doing nothing is not an option.
So what are the solutions? Here are seven points of action we believe would help:
- Develop an honest and realistic long-term ten-year strategy to address waiting lists with targets and timelines underpinning a sustained, unrelenting focus on the task from civil servants, managers and clinicians. This should replace the charade of targets that are never met. The plan should be public with named individuals responsible for its delivery to ensure accountability and transparency.
- Step up the use of private hospitals across the UK and Ireland in the short term: this is the only source of more care which is immediately on tap.
- Focus on ensuring that the right patients are being put on the list and prioritised – not those who could be treated in the community. This work will be being done by trusts, but with limited transparency.
- There must be a long-term workforce plan, in particular for nursing where shortages are severe. International recruitment is the easiest immediate source of staff.
- Data from electronic records and soft intelligence must be combined to identify bottlenecks and focus resources on addressing them. This may be more feasible if Northern Ireland effectively uses a single list across the country: it is notable that England is currently moving towards managing lists in bigger units of around 1 million people.
- Plans for “elective care centres” to concentrate staff on single sites where they can work more efficiently must get underway at speed: progress so far has been piecemeal and limited.
- Where possible, planned care should be put on different sites to emergency care so that progress can keep being made without beds being taken up by surges at A&E. The concentration of planned care at the South-West Acute Hospital in Enniskillen during Covid-19 is a good example.
It is not a law of nature or geography that people who are unwell in Northern Ireland should have to wait longer for care than elsewhere. We are sadly unlikely to see lists as short as we might hope while the legacy of Covid-19 remains, but the level of underperformance compared to elsewhere suggests there is a great deal of room for improvement.
This blog was originally published in the Belfast Telegraph on 28 May 2021.