Intended for healthcare professionals


Can reforming the operating model help Northern Ireland out of its healthcare crisis?

BMJ 2023; 382 doi: (Published 05 September 2023) Cite this as: BMJ 2023;382:p2033
  1. Deirdre Heenan, professor of social policy, senior associate of Nuffield Trust
  1. Ulster University, Northern Ireland, UK

Fundamental changes in the operating model of the health system are urgently required to tackle the healthcare crisis in Northern Ireland, writes Deirdre Heenan

Northern Ireland has been without a fully functioning devolved government since February 2022, when the Democratic Unionist Party collapsed the Stormont Executive government in a protest over the post-Brexit protocol agreement. Without an operational government, the region has languished in limbo under deeply unsatisfactory indirect rule, somewhere between being directly ruled by the UK and devolution of powers to Northern Ireland. Under this model of governance, senior civil servants are “keeping the lights on” but have extremely limited agency to make decisions.1

Twenty five years after devolution was reintroduced in Northern Ireland, we must accept that this unstable power sharing model, which has been in a state of collapse for 40% of its existence, has been catastrophic for the healthcare system.2 Despite higher levels of spending per capita on healthcare than other UK regions, outcomes in Northern Ireland are by far the poorest and there is no meaningful plan or strategy to improve this.34 Restoring devolution and getting the executive government back up and running with a health minister appointed is desirable but will not be enough to resolve the underlying systemic issues.

The absence of a local government in Northern Ireland has compounded the chaos in health care but is not the cause of policy dysfunction. Crisis is a word often bandied about in health care, but the abysmal position in this region cannot be overstated. Northern Ireland’s healthcare system is the worst in the UK by some considerable margin.5 The statistics reveal a deteriorating situation and a system that is out of control. Waiting lists have spiralled since 2013, due to a combination of factors including poor financial planning, a lack of accountability, workforce issues, a significant reduction in the use of the private sector, and difficult political decisions repeatedly not taken. Almost a fifth of the population is waiting on a first hospital appointment, and more than half of those have been waiting for more than a year.6 In England, there is focus on reducing 18 month waiting lists, whereas in Northern Ireland eight year waits for a range of specialties such as neurology and rheumatology are common. Long waits mean that one in five cancer patients get their cancer diagnosis while attending an emergency department 7 A recent report by the Northern Ireland Ombudsman found “systemic maladministration” in the management of waiting lists.8

There are serious workforce challenges across the system in Northern Ireland,9 with over 2400 nursing vacancies in health and social care.3 Strike action in the autumn is the almost inevitable outcome of nurses here being told they will not be eligible for the pay uplifts agreed in England and Wales. Consistent failure to plan the workforce has undoubtably been costly and risky and has limited the quality of care provided. Uniquely in the UK, health and social care are integrated, and this should be an opportunity to deliver a seamless service. Yet social care has been neglected and underfunded and remains in the shadow of health care. A review in 2017 pointed to systemic failings in the social care system,10 but to date none of its recommendations have been enacted.

It would be easy to blame all our current woes on the political vacuum and the volatile power sharing arrangement. But the more uncomfortable reality is that our local politicians lack the courage and will required to transform health care. Multiple major reviews over the past 20 years all delivered a similar verdict. Services need to be centralised into fewer larger hospitals with increased specialisation and a focus on prevention and early intervention to avoid the fragmentation and duplication of effort seen in current services. Simply providing more money is not the answer. In 2022, reports by the Northern Ireland Fiscal Council presented a damning verdict that highlighted serious issues with governance, accountability, transparency, and productivity in the healthcare system.11

Local politicians have accepted that systemic change is required but, when confronted with unpopular choices, have waivered, prevaricated, and focused on services in their own constituencies. Healthcare reform is not easy. The public is understandably suspicious and fearful of changes to highly valued local services that often seem counterintuitive—when hospitals are closed and healthcare services reconfigured, it can seem that services are being removed rather than reformed.

It is time for a new model for the design and delivery of health care in Northern Ireland that is accountable, responsive, and operationally independent from the government. This could be modelled on the Bank of England, with a chief executive officer afforded the freedom to make long term, evidence based decisions that resist political pressure. One CEO should be responsible for the overall healthcare system to overcome the limitations of the disjointed current system in which different trusts each have their own CEO. An independent body responsible for health care with a chief executive appointed for five year periods and an accompanying budget could help to bring stability and continuity with open and accountable decision making to a system that has been plagued with political indecision, short term fixes, and sticking plaster solutions. Campaigns to inform the public about the roadmap for change would improve transparency, increase public confidence, and restore trust. In publicly funded healthcare systems autonomy needs to be matched by accountability for how resources are used.

This situation in Northern Ireland would not be tolerated in any other region of the UK. Decades of prevarication and political failure to make the necessary decisions have had a disastrous impact on health and social care. The time for fundamental change is long overdue.


  • Competing interests: None declared.

  • Provenance and peer review: Commissioned, not externally peer reviewed.