Change or collapse: Lessons from the drive to reform health and social care in Northern Ireland

Three years after Rafael Bengoa’s blueprint for improving the Northern Irish health service, this report uses interviews with health service leaders in Northern Ireland as well as outside experts and clinicians to assess which factors are helping or hindering Northern Ireland's efforts to change its health and social care system, finding that the political vacuum and culture of centralisation are impeding reform.


Published: 10/07/2019

ISBN: 978-1-910953-67-9

Download the report [PDF 524.8KB]

The health and social care system in Northern Ireland has seen seven fundamental reviews setting out major changes of direction in the last 20 years. Each has delivered a similar verdict: the country needs to reduce its reliance on hospitals, centralise some services to achieve a critical mass at a smaller number of sites, and focus more on prevention and keeping people healthy.

These culminated in the detailed and wide-ranging 2016 review by Spanish health care leader Rafael Bengoa, Systems not structures. Bengoa’s report concluded that:

“The stark options facing the HSC system are either 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.”

The review’s specific recommendations were then used as the basis of a 10-year plan in 2016, Delivering together, an ambitious and detailed programme of change.

This report examines which factors may be helping or hindering efforts to achieve these goals in Northern Ireland. It aims to be of interest to health leaders across different countries, especially in the rest of the UK which shares the history, remit, and funding mechanism of Northern Irish health and social care services. It forms the second in the Nuffield Trust’s series of reports looking at what UK health systems can learn from one another, following Learning from Scotland’s NHS in 2017. Northern Ireland’s system also faces its own unique context, and we hope to reflect back an external view to leaders within the country on those particular dynamics and how they affect health care.

Key points

  • There is determination in the leadership tier of the Northern Irish health and care system, and among front line staff, to make the changes in Rafael Bengoa’s 2016 review a reality. Some improvements and important initiatives are happening – but change on the ground so far is at an early stage and patchy.
  • The political vacuum in Northern Ireland is exacerbating chronic problems in taking difficult decisions. Although the civil service is doing its best to provide leadership, its role and culture limit what is possible. Without the legal powers and legitimacy held by a political leader, several very important processes of change face the end of the road.
  • This is a lesson for services elsewhere in the UK which may also face a lack of stable government or a focus on constitutional issues. While politicisation has its problems, a lack of public leadership creates serious barriers.
  • There is a lack of ambition around tackling waiting times for planned care, despite strikingly poor standards compared to other UK countries.
  • There is little sign so far of the intended shift of care and resources into care outside hospital. Despite notional integration of health and social care, there are signs that the latter remains overlooked.
  • Many people described a high degree of centralisation of power in health and social care in Northern Ireland. This is difficult to reconcile with the initiative and experimentation necessary for complicated change where the answers are not fully known.
  • Centralisation, and the exposure of the service without political leadership, seem to foster a ‘bunker mentality’ culture where openness about problems and difficulties is discouraged, removing opportunities for the system to learn.


Published: 09/07/2019

Download the full report [PDF 524.8KB]

Suggested citation

Dayan M and Heenan D (2019) Change or collapse: Lessons from the drive to reform health and social care in Northern Ireland. Research report, Nuffield Trust.