Where next for health reform?

3 Mar 2021 Ryan Miller    Last updated: 3 Mar 2021

Oliver Twist asking for more
Oliver Twist asking for more

Before Covid-19, reform of Health and Social Care was the biggest challenge facing Stormont. That challenge remains, but the ability to meet it may be diminished.


Northern Ireland’s health leaders have joined together to demand that transformation of services gets moving – at the same time as immediate pressures are dealt with.

The HSC Chairs Forum is comprised of the chairs of the 17 arms-length bodies of the Department of Health and, last week, the group demanding significant changes and extra financial support for services.

Covid-19 has done two things. It represents an ongoing (though thankfully lessening) public health crisis that has caused many deaths and serious illnesses. It has also created more pressure on the already-creaking Health and Social Care system.

Transforming HSC is a long-term commitment, a long-standing one, and one where progress has been slow. Strategic studies such as 2011’s Transforming Your Care or the Bengoa report of 2016 repeatedly laid down the principles of necessary change.

These include a greater focus on prevention, more support for making individual’s homes the centre of care where possible, centralisation of specialist services, and better cooperation (and efficiency) between different clinical channels.

Those papers also laid down the reasons behind the need for change. NI’s population is ageing (this is a good thing, people are living longer). This means more and more people are living with chronic illness (this is a consequence of having more and more older people). This means demand for services is soaring – and the balance of where that demand lies is altering, too.

Demographic changes like this mean the demand for health and social care is rising by as much as six percent year-on-year. It is impossible to meet this demand using the current HSC model. Health and social care already takes up half the Stormont budget and recurring 6% spending rises are impossible. This would lead to a doubling in total spending – and all of NI’s budget being taken up by HSC – in little over a decade.

The pandemic has not halted these demographic changes or the need for health reform.


The requests from the HSC Chairs are detailed in their consultation response to Stormont’s 2021-22 Draft Budget.

Issues highlighted in the response include potentially catastrophic workforce shortfalls. Job vacancies for nurses in some areas are as high as 40%. There are also pressures in other medical and in social care staffing.

Per the statement: “Vacancy levels are unlikely to fall in the next few years, and indeed could rise post-COVID. As a result, Trusts will continue to rely heavily on temporary staff, including high cost agency staff at significant premiums.  Obviously this represents poor value for money but more fundamentally it can actually increase the rate of permanent vacancies as staff doing the same job are being remunerated at significantly enhanced rates.”

Another issue is waiting times (in particular for elective care). These are soaring. Moreover, it involves two competing problems.

Backlogs will continue to rise as long as the health service is dealing with Covid-19. However, they will not stabilise thereafter – because the current configuration of HSC cannot handle growth in demand. Therefore, transformation is the only long-term solution.

However, those backlogs also represent an immediate challenge that needs to be dealt with asap. This challenge is not directly related to transformation and for which transformation is no solution. They represent huge numbers of people who need clinical help, many of whom have been waiting years (and could continue to wait years more).

While this second challenge is not a matter for transformation per se, it is a huge extra workload HSC will have to pursue while also reconfiguring itself for the future.

Per the HSC chairs: “Northern Ireland has by far the longest waiting times in the UK. At October 2020, there were 332,667patients waiting for a first outpatient appointment, of which 84% were waiting over 9 weeks, and 49% (162,450 people) were waiting more than a year. For inpatients and day cases, over 100,000 patients were awaiting treatment, of which 83% were waiting over 13 weeks, and almost 50% (49,956 people) were waiting more than a year. Currently, many thousands of patients have been waiting more than three years for an outpatient appointment or treatment…

“In order to recurrently address the underlying capacity issues across the HSC and to ensure waiting times do not grow again once the backlog is addressed, significant recurrent investment in staff and physical infrastructure, alongside service realignment and reorganisation between Trusts, will be required and immediate steps need to be taken to commission and fund additional medical and nursing training places now.”

Asks – and context

The HSC Chairs’ four policy asks are:

  • Additional funding is required to put HSC organisations into recurrent financial balance and to meet any inescapable pressures in 2021/22.
  • HSC organisations cannot continue to rely on in-year non-recurrent funds; instead recurrent multi-year budgets are needed to improve financial resilience and planning.
  • Additional recurrent funding, alongside transformation, is needed to enhance hospital and community services to build resilience in our HSC system.
  • Radical reform in the way elective care is delivered in NI, alongside sustained and substantial investment in workforce and infrastructure, will be required to tackle NI’s unacceptable waiting times. Immediate steps are needed to commission and fund additional medical and nursing training places.

According to the chairs: “It is widely acknowledged that HSC funding has not kept pace with demographic demand and other inescapable pressures. As a result, all HSC Trusts are carrying significant recurrent underlying deficits largely due to undelivered savings targets which have followed over ten years of significant cash savings…

“Whilst non-recurrent earmarked COVID-19 funding will be required in 2021/22 to meet the ongoing needs associated with the HSC’s COVID response, additional recurrent funding is urgently needed to maintain core services delivering essential health and social care to our population.  If HSC is to achieve recurrent financial balance, recurrent funding for demographic and emerging inescapable pressures is required for2021/22 and beyond.

“COVID-19 has further exposed the risks associated with a depleted workforce, lack of investment in ageing infrastructure, and new technologies.  There is significant pressure on hospital and community beds, and bed occupancy levels are considerably higher than those seen in high performing health systems. This, combined with shortfalls in community provision, has created a system with little or no spare capacity to deal with normal winter peaks, much less a pandemic.

“Innovative solutions and strengthened services to improve flow and quality of care in our health and social care system have been introduced in the last year and there is a compelling case to maintain and develop these further but this will require additional staff and significant additional recurrent funding.

“The proposed budget uplift for the HSC of £495.2million will not be sufficient to address existing deficits and new inescapable cost pressures in 2021/22.”


NI’s politicians are perfectly aware of these circumstances. There is also something approaching a consensus on the very broadest principles of planned HSC reform (although when centralisation leads to reduction or removal of services in specific geographical locations, you might hear a different tune from constituency MLAs and Cllrs).

On Monday in Stormont, during a budgetary debate on supply resolutions, the Chair of the Health Committee raised concerns about a lack of progress in health transformation, and an apparent reduction in ambition for what that transformation entails.

He told the Assembly: “We can and should outline the difficulties with COVID, but the situation goes beyond COVID and only outlines the need for the Department to drive forward the transformation programme and ensure that our wonderful and dedicated health and social care professionals have a system in place that is efficient, effective and reactive to the needs of the population…

“It is concerning that, at a Committee meeting just a couple of weeks ago, the Department's director of finance briefed the Committee and outlined that the funding available did not allow the Department to undertake a transformation programme with any level of ambition and that there would not be enough money in the budget next year…”

Mr Gildernew made further comments which he said were in his capacity as a Sinn Fein MLA, including: “To date, there is little evidence that any proactive planning is taking place in the Health Department: for example, there has been none of the workforce planning needed even to begin recommencing many of the non-COVID health procedures that patients have been waiting for for such a long time.

“Planning for health and social care requires long-term surety of funds. Therefore, rather than relying on monitoring rounds, we need multi-year Budgets that allow the effective, efficient planning and development of a health and social care sector that serves the health needs of our population.

“We are told by the Department of Health that the long-awaited and much-needed transformation project will be less ambitious than previously thought because the funding simply does not exist. That is hugely disappointing and does not augur well for an improved health and social care sector.”

The problem is, the department’s message is probably correct. There isn’t enough money.

Old faithful

In the long-term, the costs of not reforming HSC will dwarf the price of making the changes needed. However, without necessary short-term resources, such transformation is out of reach – and there is little Stormont can do about it.

The one thing Stormont can do – and this is an area in which it has great experience – is ask for more cash from Westminster.

Taking a the big begging bowl to London Town is the most consistent, and consistently dismal, approach to tackling Northern Ireland’s problems. However, in this case it might be the best (read: only) possible solution.

And leverage exists, in the form of another ongoing massive political problem: Brexit.

Everyone is raging about Brexit. The only politicians in Northern Ireland who were happy about Brexit in general are absolutely furious with the Brexit they got.

It is unlikely London will abandon the Protocol (although who knows?) because getting rid of the Protocol causes Boris Johnson’s government two problems – it is back to the drawing board with the EU (having reneged on an established agreement), and it also loses the ability to moan about the Protocol as a distraction from issues elsewhere.

But maybe they could bung NI a few quid (a few billion is needed, but every little helps) to deal with Health and Social Care.

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