Welcome to the Deep Dive. I'm your host, and
joining me to unpack today's topic is our resident
health policy expert. Glad to have you here.
Thanks for having me. Always good to be here
for a deep dive. So I want to start you off,
well, start the listener off really with a little
thought experiment. OK, I'm right. Imagine you're
walking down a street in Belfast or Derry. Right.
And it's raining because, well, it's Northern
Ireland, so of course it's raining. And you stop
a local to ask them about their health care.
I can guess where this is going. Right. Because
nine times out of ten, maybe even ten times out
of ten, they're going to talk to you about the
NHS. They'll, you know, complain about NHS waiting
lists or praise the NHS nurses. The logo on the
hospital even looks like the NHS logo. It does,
yeah. It's free when you walk in the door. It
cracks like a duck. It walks like a duck. And
here is where we have to basically shatter the
illusion right away. It's technically not the
NHS. No, it isn't. And it's honestly the most
common misconception about the region, even for
the people who actually live there. Which is
wild to me. Yeah, it is. I mean, while it sits
under the broad umbrella of the UK's National
Health Service, the system in Northern Ireland
is legally and structurally a completely different
beast. Right. It's called Health and Social Care,
or HSC for short. HSC. Which, let's be honest,
sounds a bit like a rebranding exercise some
consultant came up with to justify a massive
fee. It really does. But you're telling me this
isn't just an acronym change, right? The social
care part of that title is actually doing some
heavy lifting. Oh, absolutely. It is the defining
feature. In fact, for public policy nerds, and
I definitely count myself among them, the Northern
Ireland model is often viewed as the holy grail.
The holy grail of health care, that's a big claim.
Well, think about how it works in England or
the US. You have your medical care, right? Doctors,
hospitals, surgeries. That is one silo. Then,
completely separately, you have social care.
So that's nursing homes, home help for the elderly,
social workers. In England, those are run by
local councils. Right. Different budgets, different
bosses. Exactly. Different IT systems, different
everything. Which is the classic bureaucratic
nightmare. You know, you hear those stories where
you're stuck in a hospital bed, medically fit
to leave, but you can't go home because the local
council hasn't signed off on a wheelchair ramp
for your front door. Precisely. The left hand
has no idea what the right hand is doing. That
is the global standard of inefficiency. Yeah.
But in Northern Ireland, way back in the 1970s,
and then it was formalized later in 2009, They
did what everyone else dreams of. They combined
them. Medical and social. Yes. Medical pair and
social services are integrated under one roof,
managed by the exact same organizations. On paper,
this is the absolute dream. OK, so it's a unique
health care experiment that should theoretically
offer this seamless coordination between, say,
your heart surgeon and the social worker arranging
your home. Oh, that's the idea, yeah. So today,
our mission for this Deep Dive is to explore
this. Because let me get this straight. We have
a system. that was designed to be the Ferrari
of healthcare, integrated, streamlined, efficient.
But looking at the stack of research we have
for today, reports from the Nuffield Trust, the
outcome stats, the waiting lists, this Ferrari
seems to be sitting on cinder blocks in the front
yard, missing an engine and like three wheels.
That is exactly the tension we need to explore
today. The performance statistics in Northern
Ireland are currently significantly worse than
the rest of the UK. Wait, worse than England?
Because England isn't exactly having a great
time with health care right now. Significantly
worse. And that is what we're digging into. We
need to figure out why this integrated system,
which makes so much sense on paper, this perfect
structure, hasn't been the magic bullet that
experts hoped for. Why the only fully integrated
system is performing the poorest. Exactly. OK,
before we get to the why, I need to understand
that what you mentioned is called HSE. How is
this machine actually built? Is it just like...
one giant office block in Belfast running everything?
Not quite. The history actually started back
in 1948, separately from the NHS, but parallel
to it. But the modern version really comes from
the Reform Act of 2009. They did this massive
slimming down exercise. They went from 19 different
trusts. 19. Yeah, which is a lot for a population
of less than 2 million people. That's a lot of
management. Exactly. So they took those 19 and
brought them down to just six. OK, six trusts.
That seems a lot more manageable. You have five
geographic trusts. So that's Belfast, Northern,
Southeastern, Southern, and Western. And then
one ambulance trust that covers the whole region.
Got it. But here is the key difference. Unlike
in England, these trusts hold the purse strings
and the staff contracts for absolutely everything.
Everything. If you work in a mental health clinic,
you work for the trust. If you are a surgeon,
you work for the trust. If you are a social worker
checking on at -risk children... You work for
that same trust. Exactly. Okay, so if I'm a patient
in, let's say, the Southern Trust, the guy fixing
my broken hip and the person helping me wash
my dishes when I get home are ultimately answering
to the same corporate boss. That is the theory.
And that brings us to what we call the integration
paradox. I like that term. You would assume,
logically, that this integration would make the
system vastly more efficient. If you control
the whole chain of care, you should be able to
move people out of expensive hospitals and into
cheaper community care instantly. Right. No arguments
between the council and the hospital about who
pays for the bed. Just move the patient where
they need to go. And yet... Terry Bamford's analysis
from 2015 showed the exact opposite happened.
Despite this integration, Northern Ireland has
actually failed to reduce its reliance on hospitals.
Really? Yes. In fact, reliance on institutional
care, so keeping people in hospital beds or nursing
homes, is higher in Northern Ireland than elsewhere
in the UK. That feels completely counterintuitive.
Why would an integrated system cling to the most
expensive way of treating people? Bamford highlights
three main blockers, and they are fascinating.
The first one is cure politics. Of course it
is. To move resources into the community, you
usually have to close or downgrade hospital buildings.
You have to say, look, we don't need this acute
wing in this rural town anymore. Oh, I can see
that going down well. In a small town, the hospital
is basically like the church or the local football
club. You try to close it and you lose the next
election. It is politically toxic. So the building
stay open and the money stays tied up and keeping
the lights on. That makes sense. But the second
issue is even more interesting. It's a culture
clash. We have to remember that health services
are free at the point of use. Right. That's the
sacred cow of the whole UK system. You walk into
A &E, you get treated, you walk out, you never
see a bill. Exactly. But social care is means
tested. It's a paid culture. Ah, I see where
this is going. Imagine you have an elderly patient.
Let's call her Mary. Mary is in a hospital bed.
She is medically fine. She's totally ready to
go home. Now, the hospital bed is costing the
system maybe 500 pounds a night, but it's completely
free to Mary. To move her home, she needs a care
package. That care package might only cost the
system 20 pounds a day. But because it's social
care. Mary has to undergo a financial assessment.
She has to prove she can't pay for it herself.
And I'm guessing that assessment isn't exactly
speedy. Not at all. It takes time. There might
be a dispute over her savings or her pension.
So you have this perverse situation where Mary
sits in a hyper -expensive hospital bed for three
weeks. Walking a sick patient from getting in.
Exactly, while the bureaucrats argue over who
pays for the chief home care. That is maddening.
The whole point of the integration was supposed
to remove the walls, but the financial rules
just built them right back up again. Bamford
noted that the greatest difficulties lay in these
differing values. The free culture and the means
-tested culture just didn't mesh. It's like oil
and water. And then just to add insult to injury,
the tech was a disaster. Oh, government IT projects.
Always a favorite. For a long time, the IT systems
for health and social care weren't even compatible.
Plus, patient confidentiality rules often prevented
the sharing of info that the system was theoretically
designed to share. Wait, so the doctor couldn't
even email the social worker? Essentially, yes.
So, you have the outward structure of integration,
but the skeleton inside the tech and the culture
was completely fractured. It's like buying a
top -of -the -line smartphone, but not having
a data plan. I mean, it looks great, but it doesn't
actually connect to anything. That is a very
good way to put it. Okay, so the machine is jammed.
And this brings us to the really heavy stuff
in the sources, the performance crisis. I was
looking at a report from the Nuffield Trust in
2017, and honestly, the numbers are hard to wrap
your head around. They are very stark. My first
thought was, well, maybe they just don't have
enough money. That's the first place everyone
looks, but the Nuffield report completely debunks
that. Really? Yeah. It showed that spending per
head in Northern Ireland was roughly 2 ,200 pounds
a year. which is pretty much exactly on par with
the rest of the UK. So they aren't drastically
underfunded compared to England. No. But the
output, the result of that money, much, much
worse. Let's talk about those waiting lists because,
you know, we hear about waiting lists all the
time. People say, oh, the list is up. But we
need to contextualize the scale here for the
listener. It is a different magnitude entirely.
Let's go back to 2015 just to set the scene.
The waiting list target in Northern Ireland,
the actual goal they were trying to hit was 52
weeks. A year. Their goal was to make you wait
a whole year. Yes. And just for context, England's
target at that same time was 18 weeks. Wow. So
the ambition in Northern Ireland was nearly three
times worse than the ambition in England. And
they weren't even hitting that 52 -week target.
That's unbelievable. The sources mentioned that
around 16 % of the entire population of Northern
Ireland was on a waiting list. Wait, one in six
people? That's not a waiting list, that's just,
that's the population. It creates a state of
permanent limbo for the entire society. And it's
not just elective surgeries like getting a new
knee, it's emergency care too. Right, A &E. The
standard target for A &E is to see people within
four hours. In Northern Ireland, over 20 % and
sometimes up to 30 % of patients were waiting
longer than that. But there was a scarier stat
in there. The 12 -hour wait? Yep. 12 hours in
a plastic chair. You arrive at breakfast, and
you're literally still there at bedtime. In February
2022, 16 .3 % of attendees waited more than 12
hours. And we aren't talking about sitting in
a comfortable lounge watching TV. No, this is
a crowded, stressful, noisy emergency department.
Exactly. And this isn't just about being uncomfortable
or bored. I mean, this kills people. It does.
We really have to talk about the human cost here
because the stats can sort of hide the tragedy.
In 2019, Heather Monteverde from McMillan cancer
support highlighted this devastating statistic.
I remember reading this. One in five cancer patients
in Northern Ireland received their diagnosis
in an emergency department. Let's just pause
on that for a second so the listener really grasps
it. One in five. That means they didn't get caught
by a routine screening. They didn't get caught
by a GP referral. Right. It means the system
failed them at every prior step. They likely
had symptoms, maybe they were even on a waiting
list to see a specialist, but they waited so
long that the cancer grew until it became an
acute, life -threatening emergency. They collapsed,
or the pain became unbearable. They went to A
&E, and that is where they were told they had
cancer. And by that point, your options are incredibly
limited. Exactly. Patients diagnosed in A &E
have the lowest survival rates. It's a systemic
failure that is literally costing lives. And
it wasn't just cancer, was it? We saw a grim
pattern with homelessness, too, in the sources.
Yes, the death rates. In a specific 18 -month
period reported back in 2019, 205 homeless people
died in Northern Ireland. And again, to give
context, Northern Ireland is small. Very small.
It has about 2 .8 % of the UK's total population.
But those deaths accounted for more than 25 %
of the total UK homeless deaths. That is disproportionate
on a massive scale. It suggests a fundamental
breakdown in the safety net. Remember, this is
supposed to be the integrated system. Social
care and health care are supposed to be working
hand in glove. Right. If a homeless person is
at risk, the health side and the social side
should be coordinating to save them. But the
data suggests that simply isn't happening. You
know, when you read these reports, it's really
easy to get numb to the numbers. But there was
one story in the BBC sources that really grounded
this for me. It was about a woman moving from
County Armagh to Wales. Ah, the Swansea case,
yeah. So she moves to Swansea. She has a condition
she's been managing or trying to manage back
home. She goes to her new GP in Bristol, or Swansea,
I believe, and hands over her medical file. And
the reaction of the doctor was very telling.
Yeah. The doctor was shocked, visibly shocked
at the standard of care she had been receiving
in the Southern Trust. And the really heartbreaking
part was that the patient herself didn't realize
how bad it was. That's the scary thing, isn't
it? Normalization. If everyone you know waits
three years for an operation, you just assume
that's how long operations take. You don't realize
that a short flight away, people are getting
it done in four months. Right. When you are inside
the bubble, you just accept the dysfunction.
It takes an outsider. or actually leaving the
system to realize, wait, this isn't normal. It's
a classic frog in boiling water scenario. So
if the hospitals are overwhelmed and the waiting
lists are a mile long, the logical fix, the textbook
fix is primary care, right? The GPs. If we can
catch things early with a GP, we save the hospitals.
How are the GPs holding up in this storm? They
are drowning just as fast. They are facing a
massive crisis of resources and recruitment.
Back in 2017, it got so bad that the British
Medical Association, the BMA, actually took a
vote to start collecting undated resignations
from GPs. Explain that to me. What exactly is
an undated resignation? It's basically the nuclear
option. Every GP signs a formal letter saying,
I quick, but they leave the date at the top blank.
They hand them all over to the union leaders.
It's essentially saying to the government, we
have a loaded gun. If you don't fund us, we write
in today's date and the entire primary care system
collapses overnight. That is dramatic. That's
like writing a breakup letter to your partner,
leaving it on the kitchen counter and saying,
I'm not leaving yet, but if you don't do the
dishes, I'm signing this. It really shows the
level of desperation. Now they didn't hand them
in, thankfully. but the threat was very real.
But amidst all this, There was an attempt to
fix things, right? I read about them pushing
for something called MDTs. Multidisciplinary
teams. Yes. Is this the Cookstown model? Yes.
Launched in 2018. It actually goes right back
to that original integration dream we talked
about. OK. How does it work? The idea is that
you shouldn't just go see a GP for everything.
You should be able to see a physiotherapist or
a mental health specialist or a social worker
right there in the local practice. Oh, that makes
total sense. If I have a bad back, I don't really
need a doctor. Physio, keep me out of the hospital
entirely. Exactly. The Cookstown Hub had scanning
facilities, minor surgery, a pharmacy, all in
one place. It's a brilliant model. But, and I
feel like there's always a but in this story.
Always. You cannot roll out a major reform like
that across a whole country without strong political
leadership. And this is where Northern Ireland's
unique political situation completely wrecks
the party. The political vacuum. Right. We have
to explain this briefly for the international
listener. Northern Ireland's government is based
on mandatory power sharing. If the two main political
parties don't agree to form a government together,
there is no government. The whole thing just
collapses. It's not like the U .S. or the U .K.
where if the leader quits a new one just steps
in, the lights literally just go out. Correct.
And from February 2022 to January 2024, the DUP
boycotted the executive over Brexit protocols.
And obviously we aren't taking a stance on the
politics of that, but the practical reality is...
For two years, there was no health minister.
Two years. Right on the heels of COVID. Right
when the system was on its absolute knees. And
crucially... Because there was no minister, there
was no proper budget. So you can't hire staff.
You can't sign off on multi -year building projects.
You can't roll out these Cookstown models because
there is nobody with the legal authority to sign
the check. Tom Black, the BMA chair, said the
crisis boils down to workload and workforce.
Yeah. But you can't fix the workforce if you
don't have a minister. Exactly. It's like...
trying to drive a bus from the backseat. You
can yell directions all you want, but you can't
turn the wheel. And while the politicians were
arguing about Brexit, those waiting lists we
talked about just grew and grew. Okay, we have
painted a fairly bleak picture here. We have
a system that is fighting itself culturally,
drowning in demand, and headless politically.
Is there any glimmer of hope? Is there anything
on the horizon that might actually turn this
ship around? There is one major technological
glimmer, if you want to call it that. It's called
the Encompass program. Encompass. It's very corporate.
What is it? Remember how we said the IT systems
didn't talk to each other? The skeleton was broken,
yeah. Encompass is the fix. It's a massive rollout
involving Cloud21 and Tegria, which is a US company.
The goal is a fully integrated electronic health
and care record across absolutely everything.
Hold on. I have to be a little skeptical here.
Yeah. We have seen government IT projects in
the UK before. They usually involve spinning
billions of pounds and then completely abandoning
it five years later because the software doesn't
work? That is a very fair question to ask. Why
is this one different? The main difference here
is that they are buying an off -the -shelf system
called Epic, which is already used by top hospitals
globally, rather than trying to build a custom
one from scratch. OK, that's smart. And the scope
is unprecedented. It covers acute physical health,
mental health, community care, and social services.
So if I see a social worker about my housing
situation, and then three days later I end up
in A &E with a stress -induced heart condition,
the A &E doctor can actually see the social worker's
notes. That is the goal. If it works, it creates
the second fully integrated system of its kind
in Western Europe. It attempts to finally solve
that information silo problem Terry Bamford warned
about. So it brings the digital reality in line
with the structural theory. Yes. It seems like
such a basic requirement for the modern era,
doesn't it? Doctors should be able to see your
notes. But I guess in this context, it's a revolution.
It is. It's the digital infrastructure that should
have been there from the very start. Now, will
it solve the political gridlock? No. Will it
solve the funding parity issues? No. But it removes
one of the biggest friction points in the system.
Exactly. So where does this leave us? We started
by talking about a unique experiment, a place
where health and social care are one and the
same. It is a fascinating case study in the gap
between theory and reality. Northern Ireland
has the structure that health policy experts
around the world argue for. They have the integrated
model. Right. But as we've seen, structure alone
just isn't enough. It has been bogged down by
the difficulty of culture, the legacy of old
buildings, and political instability. It's a
warning, really, for any listener whose local
government is proposing this. You can't just
merge two departments, change the letterhead,
and expect magic to happen. Absolutely. The lesson
here is that integration is hard. You can merge
the organizations, but merging the cultures,
the free versus the means tested is the real
battle. If you don't fix that, you just create
a larger, more complex bureaucracy that is even
harder to steer. Precisely. That makes you wonder.
We always hear that breaking down silos is the
answer to everything in corporate and public
life. It's the buzzword of the century. But if
Northern Ireland, the only place in the UK that
actually did it, has the worst waiting lists
and the worst performance stats. Maybe the silos
aren't the biggest problem. Maybe we need to
stop assuming that integration is the automatic
magic cure for modern health care. That's the
uncomfortable question that nobody really wants
to answer, but looking at the data we went through
today, we really can't ignore it. Definitely
something for you to think about the next time
you hear a politician promising a seamless new
system. Thanks for joining us on this deep dive
into the health and social care system of Northern
Ireland. We'll see you next time.