Northern Ireland’s healthcare crisis: Does it point to Irish unification or closer cooperation?

I was at the big Ireland’s Future rally in Belfast earlier this month. The line-up of speakers was impressively broad and sometimes not obviously nationalist: from former Taoiseach Leo Varadkar to former Alliance leader Lord John Alderdice, from the SDLP’s Claire Hanna to DUP founder member Wallace Thompson, from Irish Labour Party leader Ivana Bacik to GAA president Jarlath Burns.

However the most powerful speech I heard was not from a politician about Irish unity, but from a doctor about the dreadful state of the Northern Ireland health service. It came from Tom Black, a GP in Derry’s Bogside for 35 years and chair of the British Medical Association in Northern Ireland (speaking in a personal capacity).

Dr Black started by quoting a recent article in the Economist. This warned: “If you are ever in Northern Ireland, pray that you never need a gallbladder removal, a neurology appointment or a hip replacement. For these treatments, patients routinely face waits of several years to be seen. Hospital waiting lists, on which the equivalent of a quarter of the population languish, are just the tip of the province’s healthcare crisis. According to the Royal College of Emergency Medicine, three times as many people died due to delays in emergency departments in 2022 as did during the worst year of the Troubles. General practice and social care are also on the brink. People still love the National Health Service (or Health and Social Care, as it is officially known in Northern Ireland). Increasingly, however, they admire a service that no longer exists.”1

Why is the Northern Ireland health service so bad? asked Dr Black. In the NHS in the UK as a whole, there is a 15% deficit of £32 billion annually due to many years of Tory government austerity policies and cutbacks. Half the UK’s hospital beds have been closed in the past 30 years, which means that France now has proportionately twice as many hospital beds, Germany three times and Japan four times. The UK has a below average number of doctors and nurses, and the lowest number of CT and MRI scanners per person among 16 comparable developed countries.

Northern Ireland now has the worst waiting lists in Britain and Ireland. Compared to the Republic, outpatient waiting times are twice as long (four times as long for those waiting more than 12 months); inpatient waiting times are three times as long (and an amazing 11 times as long for those waiting more than 12 months).

The North desperately needs an increase in Westminster funding for health, rather than the 2.3% cut this year which the NI Executive was forced to impose. Another factor is the very small (although growing from a low base) private healthcare sector in the North. “The biggest problem we have at the moment in Northern Ireland is that for cancer patients only 30% begin treatment within the 62 day target,” said Dr Black. “As a result we’re seeing huge numbers of late presentations with metastatic cancer [cancer which has spread to other parts of the body] where no primary cancer can be identified. As they say in Derry ‘they are riddled with it.”

Dr Black summarised the situation in NI as follows: “We can’t fix the waiting lists and they will get longer. We have no hope of competing with the Republic’s Sláintecare programme – we are East Germany and they are West. We have no hope of increased funding from the UK. We have no hope of local politicians recognising the problem and taking action. We have a collusion of anonymity with the the public, the politicians, the media and those in authority refusing to recognise the disaster that is the NHS in Northern Ireland. We need to stop pretending that we have a universal health service – it isn’t one and the only thing worse than an absent service is a pretend service.” He said many of his patients in Derry would prefer to die at home than go to the city’s Altnagelvin hospital. He said many GP practices were being forced to close because they couldn’t survive on the 5.4% share allocated to them under the province’s health budget.

One of the solutions Dr Black proposes (along with more private health insurance and the NHS to admit that it is no longer a universal service and must focus on particular specialities) is more cross-border health services. Because in contrast to the Tory cuts in the UK, investment in the Southern health service in recent years has soared, particularly since the Sláintecare programme started in 2017, and even more since the Covid pandemic. The initial impression was that the governing party, Fine Gael, were lukewarm about Sláintecare – agreed as an all-party programme – but having to deal with Covid, plus the massive inflows of corporate tax revenue into the government’s coffers in recent years, changed all that.

There are now far more doctors in the system than ever before. Consultants being paid €250,000 and more has seen a steady inflow of such senior doctors from abroad, including many from from Northern Ireland. The number of advanced nurse practitioners has also increased. The Republic’s health service now has one of the highest levels of foreign-born staff in the world, and care has only improved as a result. Care in the community, another emphasis of Sláintecare, has also improved significantly.

Cancer care is a notable success story. The number of cancer centres was reduced from 30 to eight, the quality of care has improved greatly, and Ireland now compares well with the better EU countries. The Health Service Executive is trying to develop similar integrated care strategies for other major diseases.

The Republic is not free from the challenges facing healthcare providers everywhere in the Western world: the population getting older, leading to more people with complex health needs, needing expensive treatments, with the cost of drugs sky high. Waiting lists in some hospitals are still unacceptably high, and many patients still wait long hours on trolleys before they are seen. But the Irish government has been fortunate in recent years for the sheer amount of money it can spend on its health service.

Is there an important message in Dr Black’s call for more cross-border health services for those of us who want to see the two peoples and the two jurisdictions in Ireland moving peacefully together? In a recent paper, that excellent academic researcher into Northern Ireland and the politics of Irish unity, Professor Jennifer Todd of UCD, reported on four years of conversations with groups of women, young people and migrants, north and south – who are disengaged from constitutional discussions – about constitutional change in Ireland. The participants emphasised that “issues of practical life – bread and butter issues and rights, not primarily identity and institutions” were the priorities for them. One of the research project’s findings was that “any model of a united Ireland that did not alleviate present problems of cross-border healthcare would not be good enough.”2

A small start has been made here, although it is an almost completely unsung story. The Cooperation and Working Together (CAWT) border region network of health boards and trusts has been collaborating across the border for more than 30 years on a range of services. These have included exchanges of doctors, nurses and patients (the latter crossing the border for surgery); cross-border cooperation in some mainstream services, such as Ear Nose and Throat (ENT); joint planning for services where the need exists in both jurisdictions, notably a cross-border radiotherapy centre and a cross-border emergency cardiac service at Altnagelvin hospital in Derry; and an all-island paediatric heart surgery unit at Crumlin hospital in Dublin.

Why don’t we in the Republic adopt a policy of moving towards a convergence of some of the most important medical and hospital services on the island to illustrate in the most noble and practical way possible – through the improved healthcare of the ordinary people of Ireland – that collaborating on an island basis works to the huge benefit of all? I believe that would convert incomparably more people – including those ordinary people who are unionists – to the cause of eventual Irish unity than all the nationalist rhetoric and vague promises coming from the likes of Ireland’s Future.

A final word from Dr Black on the importance of the National Health Service in Northern Ireland: “The NHS is about more than just healthcare. It is part of our social fabric, part of the glue that holds society together – it’s how we look after the vulnerable, those suffering and dying. Failure to provide a high quality health service will undermine confidence in our democratic society. Why would you pay your taxes if the sick and vulnerable are not being looked after in this way? Why would you vote for parties who are not prepared to look after the vulnerable?”

1 ‘Half of Northern Irish patients wait over a year for treatment, The Economist, 30 May

2 ‘Introduction: Democracy, disengagement and disjunctures.

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