What ‘Before the Vote’ gets right and wrong about health…

John Doyle’s Before the Vote: Planning for a united Ireland devotes a chapter to the island’s two health systems, and its main finding is hard to dispute. On the figures he reports, a far larger share of Northern Ireland’s population is waiting for hospital appointments or treatment than in the Republic, and the gap is widest for those who have waited more than a year. The chapter is less convincing on why Northern Ireland performs so badly and on what would change that. An independent study of Northern Ireland’s health service, published by the Nuffield Trust in 2019, examines a problem that Doyle acknowledges but does not fully explain: why reforms recognised as necessary have proved so difficult to implement.

What the figures show

Doyle reports that in March 2025, 529,000 people in Northern Ireland were waiting for a first outpatient appointment, 27.8% of the population, against 11% in the Republic in June 2025. He puts those waiting more than a year at 15.6% of the population here and 1.8% in the Republic, a ratio of about eight and a half to one.

Two qualifications apply to these figures. The Northern Trust did not report how long its patients waited, so the 15.6% figure is an estimate that applies the 56% recorded in the other four trusts to the whole list. The book’s summary table gives the Republic’s inpatient and day-case list as 2.4% of the population, where Doyle’s own figures produce 1.8%; neither error changes the conclusion. Mark Dayan and Deirdre Heenan’s report for the Nuffield Trust, Change or Collapse, found that in March 2019 a person in Northern Ireland was at least 48 times as likely as a person in Wales to have waited more than a year for planned care.

Doyle gives no source for his statement that “most people can see a GP within 24 to 48 hours” in the Republic, although every figure for UK GP waits beside it is referenced. The evidence available does not clearly support it. In a September 2026 Ipsos B&A poll of people in rural Ireland for the Irish Examiner, 54% said they had waited two days or more for a GP appointment, and 26% had not waited at all. The poll covered rural areas only and cannot settle the national picture. Doyle also treats life expectancy and infant mortality as measures of how well a health service performs. He accepts that health outcomes “have complex causes” but adds that delayed treatment “is surely an important factor”. Factors outside the health service, such as smoking and deprivation, affect how long people live, and the book does not separate their effect from that of the health service.

Money and organisation

Doyle notes that reform in Northern Ireland has stalled, but he places most weight on funding: he concludes that the system “is unlikely to make progress without greater British government funding”. Dayan and Heenan tested part of that explanation by estimating what England’s funding formula would allocate to Northern Ireland on its levels of need. One model, based on rates of Disability Living Allowance, put Northern Ireland’s need 29% above England’s. The authors doubted it because the number receiving that allowance in Northern Ireland later fell from 213,000 to 103,000, which they took as a sign that the rate reflected political and welfare choices more than need. A second model put need 2% above England’s, and actual funding was 5% above, within that model’s margin of error. On that analysis, Northern Ireland was not clearly underfunded for its needs.

The Northern Ireland Audit Office’s report Tackling Waiting Lists answers a different question, and its answer supports Doyle. It estimated that the Department of Health’s 2017 elective care plan would cost between £859 million and £909 million, and found that only £136.5 million was invested in it between 2017–18 and 2021–22. The 2021 Elective Care Framework needed £707.5 million of additional investment up to 2025–26. The Department told the Audit Office it had not provided the recurrent funding needed for key actions and could no longer meet the framework’s March 2026 targets. The two findings are compatible: Northern Ireland’s day-to-day budget may broadly align with its needs, while the reforms intended to improve the service have not been funded at the levels envisaged. The Audit Office did not treat money as the only cause. It also pointed to workforce shortages; emergency pressures that pull surgeons, theatres, and beds away from planned operations; day surgery spread across 19 sites with unequal access; and little capacity reserved for planned care. Doyle cites Dayan and Heenan only for a point about how waiting times are measured, and does not cite the Audit Office report. His case for more money would be stronger if he had used it.

Why reforms stall

Dayan and Heenan located much of the failure in decision-making. Northern Ireland had seven major reviews of health and social care in about 20 years, and each reached a similar verdict: rely less on hospitals, concentrate some services on fewer sites, and do more prevention, but little of this was implemented. The authors described a highly centralised system, poor workforce planning and a long-standing reluctance to take decisions that would close or move a local service. The collapse of power-sharing worsened this, and they cite a stalled reorganisation of stroke services because no minister was available. They also found that the problems “stretched back through periods of power sharing and direct rule”, and quote one participant who said that if devolved government “came back tomorrow, it wouldn’t solve our problems”.

Doyle’s own proposals meet the same obstacle. He notes that Northern Ireland’s planned reduction from ten major acute hospitals to four or five has made little progress, and holds up the Republic’s move to a smaller number of large cancer centres in 2007 as a model. Doyle cites evidence that the Republic’s reorganisation improved cancer outcomes. Evidence that concentrating specialist services can improve clinical outcomes does not, however, establish how the wider hospital network should be configured, particularly where changes affect access to other services. The obstacle here is the one Dayan and Heenan describe: the difficulty of making that kind of decision in Northern Ireland.

On 3 September 2026, Health Minister Robbie Butler published the outcome of the consultation on a regional hospital network, which drew almost 30,000 written responses. He told his Department not to proceed with the proposed grading of hospitals as local, area, general and regional centres until it had been reviewed. He also announced an Independent Reconfiguration Committee to scrutinise major or controversial changes and publish its advice, while leaving the decisions with the Minister. The next day the chair of the BMA’s Northern Ireland council, Dr Alan Stout, warned that reviewing earlier reviews would “inevitably cause delays”. Whether the committee speeds reform by giving decisions more public legitimacy, or slows it, cannot yet be known. The book shows what Northern Ireland could learn from the Republic. It does not explain how a united Ireland would remove that obstacle, and local pressures to close or downgrade a hospital would remain after a change of sovereignty.

Social care

Doyle points out that both jurisdictions integrate health and social care, unlike England, Scotland and Wales, and treats this as common ground for shared learning. He does acknowledge serious problems in social care here, including a nursing home sector that is entirely private. Dayan and Heenan found that Northern Ireland’s system was “nominally fully integrated”, with social care “the poor relation” and cuts to home care used to find savings for health services. A single administrative structure did not produce integrated care. Policy has since shifted: in March 2026, the Department of Health published a ten-year strategic plan for adult social care, with a three-year delivery plan of 33 actions. The announcement gave no funding figure, and the then Minister described the plans as balancing “ambition and realism in the current financial climate”. Later that month the Department also published a neighbourhood health and wellbeing framework, intended to move more care out of hospitals through teams combining health and social care providers, councils and voluntary organisations. Implementation began in April 2026, with 17 integrated neighbourhood teams being established, although their effects remain to be demonstrated. These are real steps, but they are not yet evidence that the balance between health and social care has changed.

Where things stand

The Nuffield Trust report is seven years old, and some figures have improved since. The Department’s figures for 30 June 2026 show 504,537 people waiting for a first outpatient appointment, 1.2% fewer than in March, with 53.7% of them waiting more than a year and a median wait of 59.1 weeks. No trust met the outpatient, inpatient or diagnostic waiting-time targets. The Department also warns that figures from the new encompass patient record system are not directly comparable with earlier data, so read the fall from the 529,000 Doyle reports for March 2025 with care. The reported reductions in the waiting lists are small, and the central problem the Nuffield Trust described, that agreed reforms are not delivered, has not gone away.

The book’s chapter on planning for unity raises one more difficulty. Doyle argues that charges for GP visits in the Republic will need to be dealt with before a referendum, and suggests the Sláintecare programme may provide the blueprint. Earlier he records that the Irish government’s 2025 Programme for Government limits the next expansion of free GP care to children aged eight to 12, which he himself describes as “a significant slowing down” of free GP care. On his own evidence, the government’s present commitments fall short of the reform he regards as necessary before a vote.

Doyle has shown that patients in Northern Ireland wait far longer for hospital care than patients in the Republic. The case for reforming Northern Ireland’s health service is strong. A case for constitutional change on health grounds would need more: evidence that a united Ireland would carry out the reforms that devolution and direct rule have both left undone.

Sources:

John Doyle, Before the Vote: Planning for a united Ireland, Dublin: DCU Press, 2026 (open access): Table 5.1, p. 98 (summary of health outcomes and waiting lists); p. 99 (“complex causes”; delayed healthcare “surely an important factor”); pp. 100–2 (waiting lists, including the Northern Trust gap and the 56% figure, p. 101); p. 102 (GP access in the Republic, no source given); p. 103 (integrated health and social care); p. 105 (“unlikely to make progress without greater British government funding”); p. 106 (2025 Programme for Government; “a significant slowing down”); pp. 107–8 (hospital reconfiguration from ten acute centres to four or five; cancer centres; nursing home places all in the private sector); p. 192 (GP charges and Sláintecare before a referendum).

Mark Dayan and Deirdre Heenan, Change or Collapse: Lessons from the drive to reform health and social care in Northern Ireland, Nuffield Trust, July 2019: p. 2 (key points, including centralisation and the political vacuum); p. 3 (seven reviews in 20 years); pp. 8–9 (waits compared with Wales; note on measurement); pp. 10–11 (funding models; Disability Living Allowance caseload); pp. 12–13 (social care); p. 14 (workforce planning); p. 22 (problems under power sharing and direct rule); pp. 23–4 (stroke services).

Northern Ireland Audit Office, Tackling Waiting Lists, web version accessed 19 October 2026: paragraphs 1.7 (workforce shortages), 3.11 (cost of the 2017 plan), 3.12 (day case services over 19 sites), 3.15 (resources needed for elective surgery), 13 (dedicated elective capacity), 22 (£136.5 million invested), 26 (£707.5 million for the 2021 framework) and 29 (recurrent funding not provided; March 2026 targets).

Northern Ireland Assembly, written ministerial statement on the publication of the hospital network consultation, Minister of Health, 3 September 2026.

ITV News, BMA warns Stormont health minister plans will cause further delays to hospital reform, 4 September 2026.

Department of Health, news release on the adult social care strategic and delivery plans, 23 March 2026; publication page for the Neighbourhood Model of Health and Wellbeing, published 31 March 2026, updated 29 September 2026 (implementation from April 2026; 17 Integrated Neighbourhood Teams).

Department of Health, news release on the quarterly waiting times statistics, position at 30 June 2026 (totals, medians, targets and the note on comparability of encompass data).

Irish Examiner, Rural Ireland Thinks: Half of those surveyed had two-day wait to see GP, 18 September 2026 (Ipsos B&A poll of people in rural Ireland; sample size not given in the article).