…so the theme we use when developing the network would be bringing the right patient to the right place at the right time. So, the most injured are identified early and we would aim to bring them to a Major Trauma Centre.
– Dr Duncan Redmill, Major Trauma Network NI, RTÉ Morning Ireland, June 2017
Health in Northern Ireland is a tricky business. By and large those charged with making decisions tend to err on the side of not making one, prefering to push it into the laps of senior civil servants whose job is to advise and action political orders.
The problems dogging the minister in terms of reconfiguration over Causeway, flow from a decision made following Bairbre de Brún’s 2002 consultation, Better Services: Modernising Hospitals and Reforming Structures (no longer accessible).
The recommendation in that paper was to cut Northern Ireland’s fifteen acute hospitals down to nine: Belfast City, the Royal, the Ulster, Antrim, Craigavon, Altnagelvin, Daisy Hill, Causeway, and the Erne (now SWAH). More on that last one later.
It has been argued that the fatal flaw in Antrim/North Londonderry was to split acute status between Causeway in the north and Antrim in the south (a short jump from Belfast’s three major hospitals – the City, Royal and Ulster, not mention the Mater).
Had Ballymena been chosen then, arguably we’d not be facing the current dilemma. Drive times from Ballycastle (currently in the Causeway) would be just on the boundary of what’s needed (45 mins), whereas a switch to Antrim would take 55–65mins.
The more immediate background to current pressures is the long overdue reconfiguration of hospital services as suggested by the Bengoa report published by the then Health Minister Michelle O’Neill as a ten year plan over ten years ago.
It was never a plan. Indeed, a cynic might read the up/down nature of the institutions (down for five up for five years) as a way of hoping such difficult decisions would be long fingered long enough until civil servants and trust officials acted in their stead.
All that Bengoa, Compton and others offered was a bare template with a lot of sensible ideas in it, but the operational end of things was to be up to the local Health Minister and the wider executive, who have all at least paid lip service to reform.
The resignation of the last health minister, Mike Nesbitt took place in less than ideal circumstances. Many have questioned (yet again) the intervention of his party leader re the ending of emergency general surgery services at Causeway Hospital.
The presumption has been this is a political problem. But that is severely tempered by where you live. There’s no serious opposition to the establishment of specialist hubs. If you’re in a serious car crash most folks know you should end up in Belfast.
All which brings me to The Erne or the South West Acute Hospital (or more commonly SWAH) as it is now known.
Nobody argues that a polytrauma case should be worked up in Enniskillen. Major trauma is a hub speciality and everybody, including the campaigners, knows it. The concern is that major trauma stabilisation cannot be done so far from an MTC.
Indeed the Irish Trauma Strategy has noted that there was no stabilisation facility in Sligo, Cavan, or Monaghan hospitals either meaning there is a significant gap south of the border too that the Republic’s government hoped would be filled by SWAH.
In addition appendicitis, bowel obstruction, perforation are the bread and butter of any acute hospital and it was one of the things the hospital was originally invested in to do. The new SWA Hospital replaced the Erne on foot of that designation.
It opened in 2012, at a cost north of £270m. But ten years later, in December 2022, weeks after Stormont was suspended again emergency general surgery (against Robin Swann’s explicit advice weeks before) was suspended and moved to Altnagelvin.
The word temporary was used, but nearly four years later and it has not come back.
The Executive fell in October, and the Ministerial post was empty until February 2024. Whatever can be said of Antrim and the Whiteabbey and Mid-Ulster closures, Michael McGimpsey signed them off and had to answer for it in the chamber.
So Enniskillen’s surgery disappeared during an interregnum, on operational grounds, which no minister has ratified since. It has only been reviewed, which is where it gets interesting.
The Western Trust says the change has worked, and points to an independent analysis showing a 24% fall in mortality. But as we reported in February, its own emergency medicine consultants don’t accept it, as noted in the regulator’s report, on page 15 they:
“…questioned the interpretation of mortality trends and whether patients receiving palliative surgical care but managed medically were excluded from reported mortality data. They refuted suggestions that patients had not come to harm and cited cases where requests for external review were not supported.”
You don’t need to be a statistician. A death rate is deaths divided by patients — leave out a group of the sickest and it falls on its own, without anything actually improving. Were they left out? The Trust knows the answer, but so far is not telling us.
Then the regulator. In January 2025 RQIA called the “double ED” (where a patient is worked up in Enniskillen, transferred, and made to wait again in Altnagelvin’s emergency department) was “deep disappointing” and required urgent action.
The report also said that…
“It should also be noted that no additional resources have been provided or commissioned to alleviate pressures experienced by Northern Ireland Ambulance Service (NIAS) to support the changed pathways in terms of increased transfer activity, or out of area journeys to Altnagelvin Hospital.”
Everyone signed up. The Department, the Trust and the Ambulance Service accepted all ten of the review’s recommendations, and the Assembly’s health committee began receiving quarterly reports on progress.
Then, seventeen months later, RQIA changed its mind. Its June 2026 inspection allowed that some patients may need a second assessment in Altnagelvin’s ED. But the same report notes: “no regional process has been established to capture this data.”
The regulator told them to stop doing it, then decided they could carry on. And nobody is counting how often it happens.
No minister took a decision to temporarily close SWAH’s surgical facilities, but it is ramifications not only affect Northern Ireland. There are gaps in Sligo, Cavan or Monaghan were people ship straight to Dublin. Enniskillen could plug two gaps.
I can’t say whether this provisional “reconfiguration” is wrong. We don’t know, but neither does anyone else. That’s the scandal. Northern Ireland must consolidate acute services to make sure the right patient gets to the right place at the right time.
But a consolidation you can’t measure through data you won’t share with public representatives isn’t reform.. It’s a form of tinkering until things break. That may be okay for big tech but given the gaps (north and south) it’s not good for our health.
Resilience is what Bengoa was pushing for, something not only our political class but our media (who endlessly cluck over relatively minor culture clashes) generally miss. The answers are usually in the detail and the detail is in the data.
The Royal College of Paediatrics and Child Health (RCPCH) recently blamed institutional instability for failing paediatrics that have left Northern Ireland at the bottom of the UK child mortality table. It certainly provides a too convenient hiding place.
We have to incentivise politicians to do the right thing. When parades come far above the need to serve every citizen (British or Irish) whether they’re in Pettigo or Cushendun, it’s hard to blame politicians for taking the easy way out of hard decisions.
Mick is founding editor of Slugger. He has written papers on the impacts of the Internet on politics and the wider media and is a regular guest and speaking events across Ireland, the UK and Europe. Twitter: @MickFealty
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