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NHS Northern Ireland – SOS

While the NHS in England, Scotland, and Wales has been under sustained pressure in recent years following the COVID-19 pandemic, underfunding, soaring waiting lists, and GP appointment chaos, the situation in Northern Ireland (NI) is even worse. 

Record-breaking waiting lists and emergency department times – the worst across the UK, healthcare staff at breaking point and leaving the region, GP practices closing due to financial issues, and a scheduled junior doctors' strike this week have seen the situation hit crisis point.

The health service in Northern Ireland is now in “absolute meltdown” say clinicians working in the region, with even the Minister for Health acknowledging that the situation is “deplorable” and “unprecedented”.

Every Part Is in Profound Distress

In a recent keynote speech at a Royal College of General Practitioners (RCP) NI event, newly reinstalled Minister for Health, Robin Swann, issued a stark warning of an “extremely difficult and worsening” financial position for health and social care services in Northern Ireland, calling for increased resources and multi-annual budgeting in an effort to address the situation. 

“We have a system that is in very real trouble. Every part of it is in profound distress. All of us in this room today know this only too well. I believe we all have a duty to be honest with the public about what we see. The risks of service breakdown are real and growing in a range of areas. I do not say this to frighten people but to help build a shared understanding. We continue to have expectations and demands of health and social care that we cannot currently meet, and on the current trajectory the situation is getting worse rather than better.” 

He said the next year is largely going to be about “damage limitation” and “preserving and protecting existing services, with all the limitations that they have, given the scale of the budgetary pressures” in the region.

Calling on healthcare staff to work together with him and pledging to push for the best possible funding settlement for health services for 2024/2025, Swann said Northern Ireland is facing “the most challenging fiscal context in any period since the Belfast Agreement”.

Doctors to Strike

On January 18, nurses, midwives, and healthcare workers took part, along with other public sector workers, in the largest strike in Northern Ireland for 50 years, over demands for pay parity with the rest of the UK. This week, junior doctors are due to strike for the first time ever in Northern Ireland, with a scheduled 24-hour walkout from March 6 to 7. The decision was voted for by junior doctor members of the British Medical Association (BMA) NI as part of a long-running dispute over pay. Of those balloted, an overwhelming 97.6% voted in favour of going on strike, the BMA said, adding that it showed junior doctors felt they had no other choice.

There will be substantial disruption to planned hospital activity, both on the strike day itself and subsequently, as services recover from the strike day. Most scheduled activity – planned operations and outpatient clinics – across all five NI Trusts will not take place on March 6 to free up the senior medical workforce. Surgical operating lists will largely be confined to emergency surgery.

Why has it come to this? A newly qualified doctor in Northern Ireland earns £26,000 per year. In England, the starting rate is more than £33,000, and in Scotland it is £32,000. The union said junior doctors' salaries in Northern Ireland have fallen by 30% over the past 15 years, and the situation is both unfair and unsustainable.

Swann, writing to the BMA NI in recent weeks about the issue, said he is moving to implement the recommendations of the Independent Review Body on Doctors' and Dentists' Remuneration's for 2023/2024. For junior doctors, this will deliver an average pay rise of 9.1% in 23/24, with those in their first year receiving a 10.7% uplift. This award will be back-dated and payable to all staff from April 2023. 

Swann added that there are higher variable supplements for junior doctors in Northern Ireland working out of hours or at weekend compared to those in England. However, the minister added that pay erosion has been a consequence of UK government fiscal policies over the last decade and, while he is committed to doing all he can to match awards given in England, “parity plus for pay awards is not deliverable”.

However, Dr Fiona Griffin, chair of the BMA NI junior doctors committee, said in a statement: “Junior doctors must be paid fairly for the work that we do and that means nothing less than an immediate, above inflation pay award and a commitment to full pay restoration to 2008 levels.” 

“The future of our profession and our health service depends on this issue being addressed urgently and we are willing to get around the negotiating table at any time to achieve this. I also call on all political representatives to show their support and join us on the picket lines on 6 March.” 

Record Breaking Waiting Lists

The latest hospital waiting list data for Northern Ireland, published last week, paints a bleak picture, with a record one in three people in the region waiting for an inpatient or outpatient appointment. 

Speaking to Medscape News UK, BMA NI council chair, Dr Tom Black, described Northern Ireland’s medical waiting lists as “frankly appalling and totally unacceptable”.

On December 31, 2023, across four out of the five NI trusts, 341,910 patients were waiting for a first consultant-led outpatient appointment: a 9.8% increase from the year before. The median waiting time was 49.6 weeks and the 95th percentile waiting time was 257.4 weeks. 

Meanwhile, 97,794 patients were waiting for inpatient or day case admission to hospitals in the Belfast, Northern, Southern and Western Health and Social Care Trusts on December 31, 2023. While this represents a 12.7% reduction compared to December 31, 2022, the median waiting time was still very high at 58.4 weeks, while the 95th percentile was approximately 5 years and 30 weeks. 

Also, just over a third – 33.9% (52,011) –­ of patients were waiting more than 26 weeks for a diagnostic test on December 31, 2023 compared with 28.7% (37,876) on the same day of the previous year.

These waiting lists are the longest in the UK, and twice as long as those in the Republic of Ireland. 

“So you could be waiting 10 years, even 12, for a hip replacement, from the time of your first outpatient appointment time to be put on the surgical list, to actually getting the hip,” Black said, adding that patients could die while waiting for essential operations.

“We’ve left our most deprived populations with nowhere to go. Those who can afford to can get it done privately. Those who can’t aren’t having things done… Our red flag urgent referrals are even more worrying. Many of those services have very long waiting lists… the patient journey is constrained at every point. It is not a time to be sick in Northern Ireland, to worry about having cancer, or to be in pain or have a joint problem.”

Medscape News UK asked the Department of Health NI for a comment on the waiting list data. It pointed to a response by Minister Swann where he said: “Can I say from the outset that I agree fully that it is deplorable that the waiting list targets have not been met since 2014. The people of Northern Ireland are not receiving the care they deserve on a timely and effective basis.” 

Waiting times in NI’s emergency departments (EDs) also hit record highs in the last 6 months. 

In December 2023, just 38.4% of patients attending type 1 EDs were treated and discharged or admitted within the government’s target of 4 hours; the lowest percentage on record. 

During the same month, 8,613 patients spent more than 12 hours in type 1 EDs, 370 more than December 2022. 

Overall, the number of patients who waited more than 12 hours in EDs last December increased 16 times compared to the same timeframe in 2016, and compared to no patients waiting that long in April 2008; again highlighting the worsening health service situation over the last 8 years. 

The percentage of ED attendances who left before being treated also hit a record peak of 8.6% in November 2023.

Vice chair of the Royal College of Emergency Medicine (RCEM) NI, Dr Michael Perry, told Medscape News UK that the unrelenting pressure on EDs is taking its toll on patients and staff. The RCEM has called for the ED crisis to be made a priority for the new executive.

“Staff are working to burnout, to keep departments running, but they should not be expected to work to their limits in this way. It is completely unsustainable. We reiterate our call for the new health minister and the Department of Health to Resuscitate Emergency Care by adopting our five priorities, with the most urgent focus to increase and maximise functional bed capacity and implement measures to retain our hardworking staff before [urgent and emergency care] implodes.” 

General Practice in Crisis

General practice is also in crisis, with growing numbers of practices closing or at risk of closure due to chronic underfunding and debt issues despite patient demand for primary care never being higher, according to Black, who is a GP based in Derry.

There were 317 active GP practices (1450 registered GPs) in Northern Ireland on March 31, 2023, compared with 350 in 2014: a drop of more than 9%. As the number of practices has fallen, the average number of registered patients per practice has increased by around 17%, from 5500 to 6439 in the same period.

In recent months there has been an increase in the number of GP practices that are struggling financially and handing back their contracts, said Dr Alan Stout, chair of BMA NI’s GP Committee. “We only have just over 300 practices now, so it is a very significant number [of contracts handed back]…. Simply put, we don’t have enough GPs now and workloads are through the roof, with a large rise in the population and an ageing population,” he told Medscape News UK.

Dr Ursula Mason, chair of the Royal College of General Practitioners NI (RCGPNI), told Medscape News UK that handing back a contract is the last resort for many GPs. 

“The current crisis, 22 contract hand-backs since March 2022, is what happens when a vital service has been underfunded for many years, alongside an insufficient focus on growing a workforce to meet the escalating needs of a population that is both increasing in size, and in the complexity of its health needs as it grows older,” she said. “Financially, practices are finding it more and more difficult to keep the doors open and the lights on, with costs rising and funding not keeping pace. Add to this the increasing demand from our patients as they struggle to manage on the longest waiting lists in the UK and realise worsening health implications of poverty and health inequality. GPs are working harder than ever before with less resources.”

GPs, and other healthcare staff are now starting to leave Northern Ireland to work in the Republic of Ireland, other parts of the UK, and further afield for better pay and conditions, Stout, Black, and Mason all confirmed.

“Recruiting GPs into substantive posts is proving almost impossible, even if affordable, for many practices. Better terms and conditions, not least being the only group of doctors within the UK without access to a state-backed indemnity scheme, is pulling our workforce away. It is not surprising therefore that, between not being able to pay the bills and increasing levels of burnout, the contracts keep on going back,” said Mason.

"Unless and until there is both a significant increase in funding, and steps are taken to address workforce numbers and workload, this crisis is likely to worsen, and we risk widespread destabilisation and potential collapse, something which the NHS in NI cannot afford,” she added.

What Now?

The crisis in the health service in NI is largely down to capacity: not enough staff or funding to meet huge demand.

There is also no doubt among healthcare service stakeholders that the political instability in Northern Ireland has exacerbated the situation. 

The Stormont Assembly and Executive were collapsed for 2 years, just resuming operation finally in February, amid a stand-off between the DUP and the government over post-Brexit trading arrangements. In the absence of ministers, senior civil servants led government departments with limited powers and growing budget issues, as healthcare staff and patients bore the brunt caused by the pollical vacuum. 

Despite promises of extra funding and the positive news that Stormont is back with a Minister for Health in place, health staff remain pessimistic about any let up in the near future. 

For now, the junior doctor strike is set to go ahead this week and GP practices continue to hand back contracts, while healthcare staff continue to look to other parts of the UK and further afield.

“We have known for years now that the health service in Northern Ireland was in decline and that has worsened over the past few years, not helped by the lack of a functioning government,” a spokesperson for the BMA Northern Ireland commented to Medscape News UK.

“The gradual demise of Northern Ireland’s health service is a source of great frustration, anxiety, and sadness for its staff and our patients. It did not need to be this way. Decisive action, alongside honest conversations with the public about their expectations and hopes for the health service, should have happened years ago, rather than now at the point of collapse.” 

Black is also pessimistic: “I don’t think this is problem we can solve. It is a dilemma we are going to have to manage. Not only don’t we have the resources to provide the service, we don’t have the resources to catch up on the waiting lists. We are going to have to prioritise what we can do, and what we have the staff and the funding to do.”

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