Beyond hospital waiting lists: the need for accountability and reform in our health system…

Ciaran O’Neill is a Professor in the School of Medicine, Dentistry and Biomedical Sciences at Queen’s University Belfast

Where we are:

We all know the health system in Northern Ireland is at a critical juncture – our waiting lists for hospital diagnostics and treatment that were the worst in the UK, have deteriorated over time. Between March 2014 and March 2023, waiting lists for an initial outpatient appointment rose by 216%1. Over the same period more than ten times as many patients exceeded the maximum target times for inpatient treatment1. Compared to our counterparts in England, it is reported that we can expect to wait seven times longer for hospital care.2

However, concerns extend beyond hospital waiting lists. Multiple issues are evident in primary care where a telephone triage system introduced during COVID has contributed to public frustration and fears around access. A recent survey found 72% of respondents were not satisfied with their local GP waiting times and 76% were worried about access to their GP.3 General practice has struggled not just with rising and increasingly complex demand but with recruitment, retention and funding issues. This has contributed to an environment where over 17 practices have handed back their health service contracts since January 2017.4

Across the UK, morale among doctors5 and nurses6 has plummeted as concerns around their ability to deliver care have risen and pay and conditions deteriorated.7 Evidence of a more febrile relationship with patients such as an increase in attacks on healthcare staff8 cannot help the situation.

The situation, however, goes beyond public and staff disquiet. Preventable and avoidable death rates – deaths our health service could avoid – have increased in Northern Ireland (between 2014/2015 and 2018-22) and increased faster among those who are less well-off.9 The situation in 2024 may well be worse.

Worryingly too are indications that public and staff are losing faith in the NI Health Service. Not only is there evidence of increased interest among GPs and the public in the delivery of primary care out-with NHS contracts,10 but the percentage of people paying for inpatient treatment in Northern Ireland has increased by 218% since the pandemic.11

These trends may actively undermine the public’s support for the core values of the NHS, widen inequalities and simultaneously rob the NHS of the staff needed to deliver care.

How we got here

In Northern Ireland, repeated reviews have produced recommendations that have failed to produce the reforms needed. There are a variety of reasons for this including our dysfunctional politics/political system.12 The absence of a programme for government – a strategic plan for government – since 2016, however, is symptomatic of a broader absence of strategic thinking. There seems to be a Micawber-like hope that something will turn up to address the problems we face, a readiness to be distracted by the urgent instead of dealing with the important.

Blame should not be laid solely at the feet of local politicians. In as much as local politicians have been left to manage the consequences of funding decisions that largely originate in Westminster, their position is unenviable. But neither are they innocent bystanders, as indicated by the reluctance to enact reforms when our situation was better. Disappointingly, there is also evidence to suggest that they have also failed to effectively hold to account those who manage the service.

As shocking as it may sound, we have not since 2005 known the number of whole time equivalent GPs that provide care in Northern Ireland. We know the number of GPs but not how many work part time or how much time they work. This is information available in other parts of the UK and rightly so given that it is central to workforce planning and good governance. Why our politicians have not demanded it, and why our health service managers have not found a way to collect it seems curious. In its most recent review of general practice in March 2024 the Audit Office noted there were no plans to improve GP workforce data nor develop a separate GP workforce strategy,13 this despite the manifest need for both.

Such opacity is conducive to neither good planning nor good governance. Neither is it conducive to persuading a public frustrated by current provision and turning in increasing numbers to private providers that they should pour more money into the service. Suspicions that under current arrangements the service is over-administered and under-managed may be hard to dislodge. If required to pay more for care, a disillusioned public (or at least those who can) may have more confidence in securing it for themselves from the private sector rather than through contributions to the publicly funded system.

What then is to be done?

Reforms in secondary care are moving, albeit they could move faster. Here funding is seen as an obstacle to the speed with which reforms can be adopted. As noted though, convincing people that they should pay more in water charges or university tuition fees, while there exists a lack of clarity around the current use of funds will be challenging. Arguments with Westminster around a more equitable funding settlement for Northern Ireland are being made and a united front in Northern Ireland may help secure this.

If the system is to be improved, however, – waiting lists for secondary care notwithstanding – greater priority must be given to enhancing primary care provision rather than obsessing about hospital waiting lists.

Primary care is the first and most frequent point of contact between the public and the service. It is the corner stone of the healthcare system. To this observer it seems probable that the appalling waiting lists we see in secondary care are in part attributable to the issues that have been alluded to in primary care. If conditions, in GP contracts contribute to recruitment, retention and an over dependence on part time staff, they will also impede the ability of general practice to act as effective gatekeepers to secondary care. They will, that is, help explain the waiting list problems. If we plan, resource and manage primary care better, we can help fix the waiting lists too. My theory may be wrong – maybe secondary care waiting lists have nothing to do with primary care but it would be a relatively simple exercise to compare referral patterns between Northern Ireland over time with those in other jurisdictions to test it.

In secondary care, an examination of whether private insurance (or out of pocket payments) affords faster access to NHS treatment – queue jumping in plain language – seems warranted while reconfiguration of elective secondary care advances. This may assuage concerns that private medicine is corrupting core NHS values or if proven to be true provoke policy makers to address a perverse and pernicious situation.

Across the system we need data to inform, management to act and courageous collective political leadership. At all levels we need accountability for actions and lack thereof.

There is much that my own discipline – economics – could offer to improve the efficiency of our services and the health of the public too, if it is tapped into. The use of incentives or “nudges” to change behaviours remains under-exploited and regularly assessing and re-assessing the efficiency and equity of services that consume over 50% of the Assembly budget in a transparent manner could help inform efforts to improve things.

To finish on a note of optimism, our health service does a lot, often quietly and well. We need it and it needs our support. The current situation while dangerous is one also ripe for change. Elections are coming where politicians will seek votes, new NHS electronic systems have “gone live” that should allow for real time interrogation of data and there is a real public and staff appetite for better services.

I have argued elsewhere, that if our politics get in the way – if our politicians fear the backlash that reform may have in local constituencies – we need to make the service accountable to politicians in a different way.12 If we don’t and don’t do it soon, the NHS as we’ve known it will, like free school milk be consigned to the history books. The implications of that will be painful and far-reaching for us as individuals and as a society.

References.

  1. https://www.niauditoffice.gov.uk/files/niauditoffice/documents/2023-10/NI%20Audit%20Office%20Report%20-%20Tackling%20Waiting%20Lists_1.pdf
  2. tps://www.irishnews.com/news/northern-ireland/health-service-crisis-one-in-three-patients-waiting-more-than-two-years-in-northern-ireland-YNWXDDLQI5EQNBNOQ6VRO57D4U/
  3. https://www.compareni.com/press/over-three-quarters-of-ni-worried-about-access-to-gp-appointments
  4. https://www.bma.org.uk/advice-and-support/gp-practices/managing-workload/safe-working-for-gps-in-northern-ireland#:~:text=General%20practice%20in%20Northern%20Ireland,unsafe%20service%20in%20every%20area.
  5. https://practiceindex.co.uk/gp/blog/news-major-report-reveals-gp-morale-has-plummeted/
  6. https://www.rcn.org.uk/news-and-events/Press-Releases/a-lost-decade-nursing-staff-demoralised-by-poor-care-and-low-pay
  7. https://www.bmj.com/content/384/bmj.q666
  8. Iacobucci G. Violent incidents at GP surgeries double in five years, BMJ investigation finds. BMJ. 2022 May 31;377:o1333. doi: 10.1136/bmj.o1333. PMID: 35640962.
  9. https://datavis.nisra.gov.uk/health/health-inequalities-dashboard.html
  10. https://www.bmj.com/content/385/bmj.q1182?utm_source=etoc&utm_medium=email&utm_campaign=tbmj&utm_content=weekly&utm_term=20240607&uaa_id=fa648506c467748e321ca0557e74d1f42f760a4ab7d9bb6002cb4a0c21097e43&utm_campaign=This%20week%20in%20The%20BMJ&utm_medium=email&utm_source=adestra
  11. https://www.nuffieldtrust.org.uk/news-item/patients-drift-towards-paying-for-hospital-care-out-of-their-own-pocket-across-all-four-uk-countries
  12. https://www.economicsobservatory.com/how-can-the-northern-irish-healthcare-system-be-fixed
  13. https://www.niauditoffice.gov.uk/files/niauditoffice/documents/2024-03/NI%20Audit%20Office%20Report%20-%20Access%20to%20General%20Practice%20in%20Northern%20Ireland.pdf

 


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