Politicians are scared to take hard decisions – and the end result is a tottering health service
Northern Ireland’s health service is collapsing. It will be worse next year, and the year after that. While failing more patients, it will cost most money to run — and the reason for that is not primarily the pandemic, but political cowardice.
This is not a surprise to Stormont’s leaders. They have been repeatedly told by the experts they have hired that this is the inevitable consequence of their inaction. Yet few politicians are prepared to accept their role in this deadly crisis.
Two weeks ago a senior health administrator warned we were “on the cusp of an emergency department having to close its doors”. Last Sunday, that prediction came true. Craigavon Area Hospital appealed to the public not to come to its emergency department, saying it would only accept patients who were dying.
It was the inevitable next stage of the health service’s implosion, and without radical changes further grim collapses will follow.
Out of a population of 1.9 million, 348,867 people are on a hospital waiting list. Even allowing for double-counting, it is a staggering percentage of the population. Waits are astronomical, with more than half of people waiting more than a year to be seen — and far longer to be treated. This problem was caused less by the pandemic than by politicians.
At the start of last year — before Covid arrived on this island — leaked figures revealed a system where in certain areas there is almost no hope of being treated.
Even those whose lives are at stake are not being seen urgently. And just because someone might not die does not mean that they don’t need urgency. Many waits are excruciating. In some places it can be 10 years before a patient can get a hip replacement.
With so many seriously ill patients unable to be seen in a planned way, it is inevitable more of them will enter hospitals as emergencies.
Within five years, the percentage of patients being treated inside four hours in emergency departments has dropped from 70pc to 48pc. In a three-month period five years ago, 281 patients waited more than five hours for treatment; but the most recent figure is that 7,396 people have waited more than 12 hours — 11pc of all patients.
The NHS, the crowning achievement of Clement Attlee’s post-war government, was founded on the Bevanite principle that “no society can legitimately call itself civilised if a sick person is denied medical aid because of lack of means”.
That principle is no longer being upheld in Northern Ireland, and this most extreme form of inequality is widening. The wealthy, and even those of modest means, can afford to buy private care if they must. The poorest have no such choice.
No politician can claim ignorance of what caused this crisis. They have repeatedly been told radical reform is necessary. We’ve had the Hayes report, the Compton report, the Donaldson report, the Bengoa report... more reports than can easily be recalled.
At each report’s heart is an almost identical message — there are too many tiny hospitals, and services need to be centralised in larger centres of excellence, supported by more home care.
Counter-intuitively, a seriously ill patient is more likely to survive if driven past their small local hospital and on to a specialist unit. Medics overwhelmingly endorse that approach — and where it has been done (in two centralised catheterisation laboratories for heart problems), lives have been saved.
Five years ago, Stormont asked Rafael Bengoa, an eminent physician and the former Basque health minister, to tell it what to do. At that point, health was already taking almost half Stormont’s budget. He warned that without reform, the system would double in cost by 2026 — without delivering any better performance.
He said the case for change was “unassailable”, that it was necessary to close some hospital services to centralise them, and that some entire hospitals may need to close.
He warned: “The choice is not whether to keep services as they are or change to a new model. Put bluntly, there is no meaningful choice. The alternatives are either planned change or change prompted by crisis.”
Politicians queued up to endorse his report. The then health minister, Michelle O’Neill, admitted that “without radical change there is no doubt the situation will further deteriorate” and admitted “recruiting additional staff alone to prop up outdated service models is not the answer”.
Writing just three months before her party walked out of government, prompting a three-year governance vacuum, she claimed: “This Executive is united as never before in its commitment to take the right, perhaps difficult, decisions.”
Contrary to the narrative that politicians won’t give enough money to health, Professor John Appleby found in 2011 that per-capita health spending in Northern Ireland was about 11.5pc higher than in England, though there was an almost identically higher local level of need. How that money has been spent is the issue.
Declassified government files show that civil servants knew 25 years ago that Downpatrick’s Downe Hospital would never be viable as a major hospital — yet several years later a new £69m hospital was built, to applause from local politicians.
Last year the hospital’s emergency department was temporarily shut, and then that closure was extended.
Despite all the major parties saying they back Bengoa — who said there are too many emergency departments — Sinn Féin issued a press release on behalf of the five main parties saying it was “essential for our community that all services are restored… at the earliest possible opportunity.”
At the time Dr Paul Kerr from the Royal College of Emergency Medicine said: “It’s unfortunate when politicians push the idea that every unit should stay open.”
A senior health figure last week privately lamented the political populism of saving every local service, even when clever politicians know it is not in the best interests of their constituents. A former Executive minister once told me their small local hospital should be closed, before adding: “But I could never say that publicly.”
Former DUP health minister Edwin Poots last week displayed unusual political honesty, accepting the crisis was because “we didn’t take the hard decisions”.
Four years ago another group of experts examined the social care system for Stormont’s Department of Health. They said that it was “a system collapsing in slow-motion” and “fundamental reform of adult care and support is required to avoid a total collapse of the system”.
That is now exacerbating the hospitals crisis because vulnerable patients get stuck in hospital — both expensive and bad for their health.
There have been small reforms over recent years, such as the increased use of multi-disciplinary teams and a specialist cataract surgery centre. But one individual involved in the process said more substantial changes had been opposed by most political parties. And now people are dying, due to this political failure.
This is not an orange and green issue — but that does not mean it is without constitutional implications. The swing voters who will decide a future Border poll are more influenced by the practical benefits of the Union than by any of the trappings of unionism.
The academic Duncan Morrow said the NHS has become the symbol of British safety and the welfare state — but that the waiting list crisis in Northern Ireland “may be the biggest threat to the Union”.
That debate can wait for another day. The life and death of people today cannot — but probably will.