NHS waiting lists
Where the government failed?
For years now there has been a worsening health crisis within Northern Ireland: the issue of HSCNI outpatient waiting lists and the associated toll on the patient’s health outcomes and their quality of life. As with many aspects of life and detrimental trends throughout our region, the Covid-19 pandemic has served to highlight and exacerbate inequalities and worrying trends.
Context
HSCNI outpatient waiting list times have been a perennial concern, anecdotal stories abound, with many patients choosing expensive private healthcare alternatives as a last resort. The many pressures on the health service culminated in the cancellation of many red-flag cancer related surgery’s during 2020/2021. Sadly during this period Northern Ireland ranked the worst of the UK regions according to figures released by the Royal College of Surgeons: https://www.itv.com/news/utv/2021-02-11/ni-has-highest-number-of-cancelled-red-flag-cancer-operations-in-the-uk . The NI budget has proved a daunting task for both the Finance Minister Conor Murphy and the NI Executive as a whole, with additional funding becoming harder to find given the current economic hardships and most of the attention of both the NI executive and the British government taken up by Brexit and the Coronavirus pandemic.
“4,630 urgent red flag procedures were cancelled between March 2020 at the start of the pandemic and January 2021”
It is important to understand the ways in which the information is processed and collected, the current figures concerning outpatient appointment times are solely related to the time it takes for a referral to be received by an HSC trust to the time the patient arrives at their first consultant-led clinic. As a result of the way in which the data is collected, we may not have a full picture of just how many people have had their first appointment but have been left waiting extended periods of time for their follow-ups/reviews.
A prescient amount of information on the issue of waiting times can be found in the Assembly briefing paper “Why are we waiting?” by Dr Lesley-Ann Black: https://niopa.qub.ac.uk/bitstream/NIOPA/3567/1/12015.pdf. The paper covers the timeframe of 2009 to 2015, the data shows that the the number of patients waiting increases nearly every year with the period of 2013 to 2015, showing a strong upwards trend of demand exceeding capacity. Most damning of all however is the repeated failure of ministerial targets over the space of several years, the number of weeks whereby a patient must be seen keeps rising and still there is widespread failure to meet the worsening targets.
Graph from the above mentioned briefing paper
Another topic of note is the knock-on effects of cancelled outpatient appointments and the shortages of clinical staff with some specialties. However, an ageing population (as in many European countries) presents significant challenges and a strong indicator of future spikes in the rate of demand. One important consideration is that it is possible to model the potential demand in the near future, “in terms of forecasting demand, clinical specialties with high demand have not changed over the last number of years, and these areas are well known to the DHSSPS. Hence, more innovative ways of managing demand and capacity are required” (pg. 9).
The lack of a functioning Executive from the period of 2017 to 2020 has led to a compounding of many health issues over that period. Thus, a public health emergency such as the current pandemic could not have come at a more difficult time with all attention being placed upon case numbers, deaths, and available beds.
Statistical analysis
In the most recent quarterly publication of statistics by NISRA and the Department of Health, we can see clearly some of the effects of the Covid-19 pandemic and the real world figure in comparison to the ministerial targets: https://www.health-ni.gov.uk/sites/default/files/publications/health/hs-niwts-cancer-waiting-times-q3-20-21.pdf . Firstly, the 9-week target was not reached with a total of 85.3% of patients waiting longer than the targeted 9 weeks for an appointment. Additionally, the target that no patient should wait longer than 52 weeks for their first outpatient appointment, by the 31st December 2020 the target was not achieved by HSCNI as a whole and the same applies for each individual regional trust, with 52.9% waiting longer than 52 weeks (pg. 6,7).
Trust breakdown of % treated in 62 days
The breakdown of the number of patients waiting by surgery reaffirms long running trends, General Surgery comprises the largest portion of those waiting longer than 9 weeks at 38%, followed by Ear Nose and Throat (ENT) at 14% and Gynaecology at 12%. (pg. 6). A shocking statistic stated by former SDLP leader Mark Durkan was that the number of patients awaiting their first consultant-led outpatient appointment (105,486 in 2019) was at a rate 100 times more than in England with a population 30 times smaller. This statement was later verified by Fact Check NI.
Funding
Funding has been a significant issue for the NHS generally since its inception. This issue was further complicated during the years without a Stormont Executive. In the absence of a minister, leadership of government fell to senior civil servants and the then Secretary of State for Northern Ireland, Karen Bradley. The lack of a budget between these years and the lack any health legislation undoubtably led to a further stagnation within the realm of health policy.
An interesting analysis of the difficulties of this period can be found in a Westminster Northern Ireland Affairs Committee report from 2019 (https://publications.parliament.uk/pa/cm201919/cmselect/cmniaf/300/300.pdf). One aspect of key importance in this report is an assessment of the funds (£200M) which came about as a result of the confidence and supply agreement arranged between the DUP and the Conservative party. However, as a contribution to the report, both Acton for Children and the Royal College of Surgeons echoed sentiments frequently heard surrounding health funding, primarily that while one off injections of funding may help and make for a good headline, they are not a long term solution (pg.15).
Graph showing the increase in NI cancer cases over the years
Short term planning under the constraints of 1-year budgets is an area of concern to other groups such as the Royal College of Nurses, Ulster University and The Northern Ireland Council for Voluntary Action, funding insecurity and an increased pressure to implement cost saving measures has meant that there has been no clear basis with which to build the HSC and transform services as had been hoped (pg.18,19).
A key function of the report is to highlight that one of the greatest difficulties facing the HSC is the recruitment, training, and retention of clinical staff. Critical shortages of specialised staff has had an increasingly detrimental impact on Cancer services particularly, “The 62 day target has never been met since its introduction; the 31 day target has not been met since December 2013; and the 14 day breast cancer target has not been met since March 2018” (pg. 23).
Royal College of Nurses striking in 2019
Shortages have been the result of a lack of funding but also a lack of political leadership, the vacancies in key roles are an issue which continues and the disparity over pay when compared to Britain ultimately erupted in the unprecedented strike actions of 2019 which involved the Royal College of Nurses, Unison and NIPSA. Many believe that the disruption and severity of the situation acted as a catalyst for the return of an NI executive in January 2020.
A recurrent theme of the Northern Ireland government has been the lack of policy plans or strategies. Primarily there has not been an updated cancer strategy since 2008 in stark contrast to England, Scotland and Wales, “Without an integrated, long-term vision for improving cancer services under the direction of a well-conceived strategy, cancer services in Northern Ireland will struggle to keep pace with demand” (pg.24,27). Ultimately the campaigning of groups such as Cancer Research UK led to work starting on a new NI cancer strategy which featured as a commitment in the New Decade, New Approach agreement.
The Northern Ireland 2020 budget is a key concern, certainly Finance Minister Conor Murphy has made every effort to manage expectations in line, Murphy is quoted as saying: “With increased demands on public services, and taking account of inflation, it will be a challenge merely to deliver existing services at their current levels” (https://www.bbc.co.uk/news/uk-northern-ireland-55690315 ).
While the NI executive remains outwardly committed to the plan of the 2016 Bengoa report and it’s 10 year vision of service transformation, it remains to be seen if these aims will translate into a systematic change of the HSC or a continuing decline in services.
Conclusion
Outpatient waiting lists alongside several other health crises have seen successive Executives come and go without a clear change in services or their ability to reach ministerial targets. Currently this crisis finds the HSCNI at breaking point, however that has been the case for several years and what is needed most urgently is an increase in recurring health funding in combination with a strategy to train and retain clinical staff to fill vacancies and the potential use of the private sector as a means of clearing the waiting list backlogs and restoring public confidence.