Underinvestment underpinning ‘alarming’ waiting list growth
The availability of just 15 per cent of required funding to implement the Department of Health’s five-year plan to substantially reduce waiting times has contributed to an “alarming growth” in waiting lists, a report by the Northern Ireland Audit Office (NIAO) has found.
In a comprehensive report focusing on growing waiting lists for elective (planned) care, Northern Ireland’s Comptroller and Auditor General, Dorinnia Carville, has also highlighted a Department of Health concession that updated and more elementary targets for 2026, cannot be met.
Highlighting an “alarming growth” in both the number of patients on elective care waiting lists, and the length of time they wait for assessment and treatment, Carville describes it as “hugely disappointing” that after several previously failed waiting time strategies, the Department has acknowledged that the Elective Care Framework targets for 2026 cannot be met, less than halfway into its lifecycle.
The waiting list crisis in Northern Ireland is evidenced by a 185 per cent rise in the number of patients waiting for either an initial outpatient appointment, inpatient treatment, or diagnostic test over the last nine years. While there were 244,000 people waiting in March 2014, this figure increased to 696,000 patients as of March 2023.
Equally, now more than half (54 per cent) of those awaiting inpatient treatment wait longer than a year, compared to just 14 per cent doing so in March 2017, while just under half (49 per cent) wait over a year for an initial outpatient appointment, more than double the number waiting in 2017.
The NIAO report highlights that a failure to secure longer-term budgets for Northern Ireland Civil Service departments has persistently hindered the development of more sustainable funding and planning.
In 2017, a transformation-themed five-year elective care plan published by the Department estimated the cost of implementation to be between £859 million and £909 million. Despite the significance of the crisis, the NIAO estimates that only 15 per cent (£136.5 million) was made available, with a further £56 million (6 per cent) allocated over two years through the confidence and supply agreement with the UK Government.
Following the restoration of the devolved institutions under the New Decade, New Approach agreement, an updated elective care framework estimated that £707 million was required just to ensure that waiting times did not exceed one year for either an outpatient appointment or inpatient treatment by 2026, a target which is expected to be missed.
The impact of Covid-19 in exacerbating the waiting time crisis is acknowledged in the report. However, it highlights that the deterioration in waiting times is long standing and identifies the growing gap between rising population demand for care and available funding as the most significant contributor.
For example, research shows that in Northern Ireland, one-quarter of local cancer diagnoses between 2012 and 2017 were made in emergency departments.
Around 26 per cent of the total Northern Ireland population is estimated to be currently on an outpatient or inpatient waiting list and the report emphasises the recognised personal health and economic costs which are associated with lengthy waits for patients, not least the risk of developing further debilitating and complex conditions.
Highlighting the scale of the worsening problem, between March 2014 and March 2023 the number of people waiting for an initial outpatient appointment has risen by 216 per cent, those awaiting hospital admission has risen by 147 per cent, and those awaiting diagnostic tests are up 151 per cent.
“These trends show how the health and social care sector and its staff have been facing significantly growing demand for care for some time from a population which is living longer. At the same time, trusts’ annual budgets have not maintained pace with this,” the report states.
“This has contributed to the Department of Health not achieving any of its elective targets at the Northern Ireland level in any year since 2013/14, despite having significantly lowered these. Waiting times have hugely deteriorated since then, with Covid-19 pressures further worsening outcomes.”
Additionally, how the Department of Health in Northern Ireland records total time patients wait is less transparent than other UK regions, where total waiting time is measured from outpatients referral to completion of treatment. However, a rough comparison of data suggests that the number of patients on the health and social care waiting lists in Northern Ireland (26.3 per cent), is higher than in Wales (24 per cent), and significantly higher than in England (12.4 per cent).
Equally, only 5.4 per cent of people in patients in England wait over one year for assessment or treatment, compared to 51 per cent of patients in Northern Ireland.
The report does flag some limited progress, namely the opening of Northern Ireland’s first two dedicated regional day care centres at Lagan Valley and Omagh hospitals, as well as varicose vein and cataract centres. Three elective overnight stay centres have also been introduced to boost capacity. However, the NIAO states that evidence suggests Northern Ireland remains behind the rest of the UK in developing dedicated elective care capacity.
“Despite the remarkable efforts of HSC staff over recent years in trying to cope with rising patient demand, the deterioration in elective waiting time performance is stark,” says Comptroller and Auditor General, Dorinnia Carville.
“Unless and until a longer-term, sustainable funding framework to enable health service transformation is established, the Department will likely have to address the most pressing clinical waits through available short-term funding. This approach is totally unsuitable and almost certainly stores up huge problems for the future.
“The Department and the wider health and social care sector must continue to plan how any additional resources, which might become available, can be used to maximum effect and successfully drive transformation.”
