Intended for healthcare professionals


Northern Ireland’s budget offers little hope for improving healthcare

BMJ 2024; 386 doi: (Published 04 July 2024) Cite this as: BMJ 2024;386:q1480
  1. Deirdre Heenan, professor of social policy
  1. Ulster University, Belfast, Northern Ireland

Healthcare in Northern Ireland requires more funding to tackle high levels of need, but reform is also essential to improve deep structural issues and create a sustainable system, writes Deirdre Heenan

On almost every indicator, Northern Ireland’s health and social care system performs worse than every other region in the UK.1 A decade of underfunding, policy dysfunction, and political cowardice has left the healthcare system in a parlous state. The restoration of power sharing in February 2024 brought hope that politicians would get on with the job of tackling the myriad challenges facing Northern Ireland. Being without a devolved government exacted a catastrophic toll on public services as it was not possible to implement any new legislation or agree budgets. Despite restoration of the government, the recently announced 2024/25 budget doesn’t offer promise for recovering health and social care in Northern Ireland and will likely mean further cuts.

Securing a fiscal framework that can tackle current underfunding and provide a sustainable financial settlement is essential if a short term sticking plaster approach is to be avoided. But suggesting that our health and social care woes are entirely caused by insufficient funding is letting our politicians off the hook. Blaming the UK government is a useful distraction, but the Stormont government cannot divest itself of responsibility. Health is fully devolved to Northern Ireland and if we don’t transform the service as outlined in numerous reviews, it will continue to consume more and more of the budget.

The two year absence of government before February 2024 coincided with soaring inflation, increasing pay pressures, and underfunding of public services in Northern Ireland. A report by the Nevin Institute highlighted that Northern Ireland’s total current budget allocation is below what is needed to provide public services on par with England.2 The deal that was agreed to restore devolution acknowledged this gap in funding. A needs based funding factor will be included in the Barnett formula—a mechanism used by the UK Treasury to adjust the amounts of public expenditure allocated to Northern Ireland and the other devolved nations. This needs based “top up” will be set at 24% and will be in place from 2024 to 25. Measures in an interim fiscal framework meant that an extra £24m was immediately available.

However, the much anticipated budget of 2024/25 brought little cause for celebration.3 The health department was allocated £7.76bn, representing just half of the total block grant. According to the health minister Robin Swann, this budget allocation actually represents a 2.3% cut to health and social care funding and means that “people would be at increased risk of harm.” In a letter in April to Stormont’s health committee, he said it was his duty to inform members of the “incredibly serious consequences” of the budget.4

Swann reported that he had asked health and social trusts to come up with savings plans to tackle this budget shortfall. He described their responses as the “most alarming” advice that he had received outside the pandemic. Making these savings could involve a cut of 400 acute hospital beds and approximately 500 care home beds, a reduction of 1200 staff, and a reduction of more than a million hours of domiciliary care support. Healthcare trusts are delivery bodies and have very few options when it comes to saving money. Cuts invariably fall on the same “easy” targets, such as social care and training. Reducing social care packages is relatively straightforward in commissioning terms, but is a short term measure that will be costly and counterproductive in the longer term because it increases pressure on the rest of the system.

The Department of Health is responsible for policy and strategic direction. It needs to produce a long term plan for health and social care that sets out how systemic issues such as recruitment, waiting lists, and over reliance on agency and locum staff can be tackled. Numerous reports have concluded that Northern Ireland has too many hospitals with services spread too thinly across too many locations.5 Without radical reform this will get worse every year. Staffing pressures are also linked to this fragmentation, and without change the cost of agency and locum cover will continue to increase. Funding must be prioritised to improve the underlying issues, not the symptoms. We cannot simply keep demanding more money to put into a leaky bucket. A comprehensive, long term strategic plan is essential. The department must set out a clear path to achieve an agreed vision and publicly report on progress against it.

Reports by the Fiscal Council and the Nuffield Trust have highlighted systemic issues with productivity, governance, inefficiencies, and accountability67 but have largely been left to gather dust. A radical approach is required which includes proposals for economies of scale, reconfiguration on services, plans for the disposal of assets, and crucially a review of departmental activities and functions.

The deep structural issues that continue to bedevil the health and social care system in Northern Ireland cannot be solved through short term funding injections, and a refusal to grasp the nettle of reform. More funding is required in Northern Ireland to tackle relatively high levels of need and ensure financial stability, but this is only half of the story. Creating a sustainable healthcare system is impossible without reform.


  • Competing interests: none declared.

  • Provenance: commissioned, not externally peer reviewed.