Political deadlock blocking health reform in Northern Ireland

Author: Jo Carlowe

A political vacuum and a culture of centralisation are impeding reform of the health and care system in Northern Ireland.

This is the message from the independent think-tank, the Nuffield Trust, which, in its report ‘Change or Collapse’, published today, argues that although health service leaders are committed to change, a ‘lack of political leadership’ is blocking progress. In addition, it warns this is 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 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, the report states.

It further identifies a ‘lack of ambition’ as 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, added: “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…How bad does it have to get before urgent action is taken?”

Responding to today’s findings, Dr Alan Stout, a member of the British Medical Association’s Northern Ireland Council, said: “This report highlights the scale of the challenge to reform the health and social care service here and the need for engagement with everyone working in and using this service on the reform process - including doctors, patients, healthcare staff and politicians.

“As the report points out we have seen numerous reviews of the health service in Northern Ireland, but the current situation will only continue to deteriorate unless the sustained and meaningful transformation as outlined in ‘Health and Wellbeing 2026 - Delivering Together’ is implemented. Although some progress has been made on transformation, the scale of reform needed can only happen with a Minister and legislative assembly in place to sign-off on this reform, and a high level of leadership and engagement right throughout the system.”

Commenting to OnMedica, a Department of Health spokesperson said: "Transforming how health and social care services are delivered was always going to be a challenging and long-term task. Important progress has been made, notwithstanding the political and budgetary uncertainties of recent years. There is a collective determination across the health and social care system to build on that progress and deliver on the transformation agenda."