Intended for healthcare professionals


Northern Ireland: Political ambition is needed to save health care

BMJ 2024; 384 doi: (Published 22 February 2024) Cite this as: BMJ 2024;384:q462
  1. Deirdre Heenan, Professor of Social Policy
  1. Ulster University, Belfast, Northern Ireland

The new devolved government of Northern Ireland must lead on recovering and reforming the healthcare system, argues Deirdre Heenan

After a two year hiatus, the power-sharing Executive government and its governing body, the Assembly, in Northern Ireland have been restored. An effective Executive and Assembly are the best placed institutions to govern Northern Ireland, especially when it faces challenges that are urgent, significant, and varied, but lessons must be learnt from past failings. The region has been without a devolved government for five of the past seven years, and this political vacuum has had devastating effects on public services. In a population of 1.9 million, there are over 400 000 people currently waiting for their first consultant-led outpatient appointment after referral, an increase of more than fivefold since 2008.1

Successive suspensions of the Stormont government have meant that political oversight in crucial decisions on budgets, transformation, pay, and policy direction have been put on hold, including in health care.2 The principle of universal, equitable, comprehensive health care free at the point of delivery has been eroded in Northern Ireland, and the health and social care system is on the edge of collapse.3

Spiralling waiting lists, ambulances queuing outside hospitals, people being treated in hospital corridors while medically fit patients cannot be discharged, emergency departments closed to the public due to overcrowding, and a depleted, exhausted workforce are just some of the symptoms of a service crumbling. These scenes, that would have once been unimaginable, have become commonplace.

Repeated failures by previous executive governments to take tough decisions have destabilised the health and social care system. There is no strategy to tackle waiting lists or plan for recovering the workforce, nor is there funding to support this. Proposed elective care centres and multidisciplinary hubs are yet to be fully rolled out. There is also a draft social care strategy that has not been actioned, proposed reconfiguration of services that has not happened, and a women’s health strategy that was promised but is yet to be delivered. A lack of political courage and unwillingness to take unpopular but necessary decisions has led to slow and uneven change.4 Despite multiple, high profile reviews all pointing in the same direction of travel, little transformative change to Northern Ireland’s health system has been seen.45

The challenges facing health and social care in Northern Ireland are significant and multi-faceted. Firstly, the healthcare system must be stabilised, and key to this will be tackling the workforce pressures. The system is losing its most valuable asset at alarming levels. Primary care is the backbone of health care, and it is at breaking point. GPs are handing back their contracts in unprecedented numbers, with a 9% decrease in the number of active GP practices in Northern Ireland from 2014 to 2022.36 Staff are burnt out and feel undervalued, and many have already left. Immediate action must be taken to restore pay parity for nurses, allied health professionals, and other healthcare workers in Northern Ireland as they are the lowest paid in the UK and are yet to be offered a pay uplift for 2023-24.7 Despite demoralisation and frustration, there is enormous willingness among staff to help the healthcare crisis.

Secondly, the Bengoa Plan8 produced a set of general principles back in 2016 to ensure a sustainable system of health and social care. If there had been political stability, this plan could be eight years into its delivery. There is an urgent need to produce and agree a 10 year roadmap for transforming the healthcare system.

To date, change has been haphazard and fragmented. Reconfiguration of the health system has been resisted by the public as its implications are poorly communicated and can appear counterintuitive, with many feeling that services are being removed rather than centralised.9 Keeping people in the dark has allowed misinformation and fear to take hold. Plans to reform the healthcare service should be accessible to all and comprehensive in setting out priorities, targets, performance indicators, milestones, and desired outcomes in transforming the healthcare system.

Getting this plan right and ensuring its widespread adoption requires relentless focus on transformation of the ailing healthcare system. To provide leadership and governance in this challenging environment, the Executive and Assembly must strive for unity of purpose despite political differences.

There will be no quick fix for Northern Ireland’s problems. But, with the government restored, there is an opportunity to progress some priorities that could bring big improvements to people’s lives1011 in areas including reducing waiting lists for care, health service transformation, and budgets for schools, infrastructure, childcare, poverty, and climate change.


  • Competing interests: none declared.

  • Provenance: commissioned, not externally peer reviewed.