Sorry, we're closed: Northern Ireland Government shutdown

08 March 2019

The government shutdown in Northern Ireland is having far-reaching effects on community practice and the health of the nation. Journalist Linsey Wynton investigates.

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While the build-up to Brexit has been a time of uncertainty and cited as the spark for significant NHS staff losses in England (Harford, 2018; King’s College London, 2018; Press Association (PA), 2018a), the major concerns for community practitioners and all health professionals in Northern Ireland (NI) go beyond even Brexit and the Irish backstop. For the past two years, there has been no functioning government.

In January 2017, the NI Executive broke down following a row between the two main political parties (see Government breakdown) (Kelly, 2019). Health is of course a devolved issue in NI (as it is in Scotland and Wales). Having no political decision-makers in place – and after almost a decade of austerity – there was inevitably going to be an impact on community practice and healthcare in general. But just how bad is it?

‘Workforce planning issues continue, with a shortage of nurses, doctors and consultants,’ says Roy Beggs, an Ulster Unionist spokesperson on health and Member of the Legislative Assembly (MLA). ‘[Only] a limited amount of longer-term investment and changes are occurring as a result of the absence of political approval. [And] our waiting lists at A&E and for elective care would not be tolerated in other parts of the UK.’

‘Waiting lists are out of control,’ agrees Professor Deirdre Heenan, director of the Centre for Health and Wellbeing at Ulster University. ‘We have the highest levels of suicide in the UK, the highest levels of self-harm. People are dying unnecessarily. And there is widespread inertia.’

‘For children, if this stalemate continues it means our ability to make progress will fall further behind where it already is for big-hitters... mental health, childhood obesity, infant mortality and childhood mortality’ 

Meanwhile, a scorecard on the state of child health published by the Royal College of Paediatrics and Child Health (RCPCH) represents a bleak forecast for NI, with no improvements in combating childhood obesity and a deteriorating mental health crisis (RCPCH, 2019).

‘For children in NI, if this stalemate continues it means our ability to make progress will fall further behind where it already is for big-hitters – difficulties managing mental health, childhood obesity, infant mortality and childhood mortality,’ says Dr Ray Nethercott, a consultant paediatrician and RCPCH Ireland committee member. So what exactly is going on?


Lack of legislation

With no health minister in place, new laws cannot be signed off. Roy uncovered the scale of the gridlock with a Freedom of Information request in September 2018. It revealed 19 healthcare strategies and new laws awaiting sign-off (Young, 2018).

Six items of legislation were awaiting Assembly approval, including laws on supporting breastfeeding in public and banning smoking in cars with children (Bell, 2018). There were also 13 healthcare strategies pending ministerial endorsement, including the Bamford review of mental health and learning disability, the Protect Life 2 suicide prevention strategy and new proposals for looked-after children (Department of Health (DH) NI, 2015a; 2015b).

‘In the absence of a health minister and an NI Executive, decisions are not being made, and transformation of healthcare in NI is not delivering the necessary improvements,’ says Roy. ‘We need a minister in place and a mechanism to approve new legislation to improve the community health in the long term.’


Swelling waiting lists 

Health visitor vacancies have meant almost 700 children in NI missed their first- and second-year HV assessments in 2018 (Connolly, 2018). And waiting times in hospitals in NI are the worst in Britain. Almost a third of patients in NI (30.8%) have waited more than a year to see a hospital consultant – a staggering 113,937 people – compared to 0.1% of patients in England, some 3156 people (Nuffield Trust, 2019; DH NI, 2018; Information and Analysis Directorate, 2018; NHS England, 2018).

Prescriptions for analgesia are at record levels (Smyth, 2018a), and GPs have said patients are waiting up to five years for operations, prompting some to pay for private surgery (Griffin, 2019; Smyth, 2018b).

CPs are feeling the effects. ‘Ultimately that affects our families,’ says Janet Taylor, chair of the CPHVA Executive and a Belfast-based nurse manager. 

‘Our families don’t live in isolation. They are also attending appointments, and if there is a lag behind that ultimately will affect the health of everyone.’

‘For hip, knee, those types of operations, people are being asked to wait three years – it is appalling,’ says Professor Heenan. ‘You think about how you would be affected – your mental health, your ability to work, but also you are constantly back to the GP wanting pain medication, wanting to know what has happened to your referral, so you are clogging up the system.

‘We are largely running now a two-tier system. The bottom line is if you need to see a psychiatrist or psychologist or if you need an operation you will pay for it. Your family may not necessarily be well off, but otherwise it is never going to be resolved.’

Voice of reality

Mary Duggan is a recently retired HV from Mid Ulster who now does some bank shifts.

As a practitioner on the ground, the major impact on health I am seeing is the impact of austerity on families and the need for foodbanks. In recent years that has increased considerably with the roll-out of Universal Credit. That seems a much bigger issue than the lack of an executive.

There has also been a distinct lack of workforce planning in relation to health in securing nurse training places, which has a knock-on effect.

CPs felt our former health minister Michelle O’Neill had got it in relation to prevention (DH NI, 2016a). The Bengoa report was about transforming services and investing in primary care, and the frustration is that has not been driven forward at the speed we would have liked (DH NI, 2016b).

In England, there have been different waves of funding for perinatal mental health but that has not been actioned here. With mental health for children – and parents – with possible diagnosis of autism, assessments can take a year.

Mental health has such an impact on everything. It’s about timely care. If you’re waiting months for services, then those conditions are becoming much more entrenched and are going to need more care, for longer.

School nurses have the skills and expertise to deal with mental health issues within schools. But they don’t have the staff to do that in a timely manner.

With the Healthy Child, Healthy Future programme, we have vacancies that are not filled, so assessments are not being delivered on time. So, for school children, that early intervention, which health visiting is all about, is not happening in terms of referrals to the relevant agencies.

I have been in the health service for 41 years and an HV for 35 years. The lack of an executive has meant the pay award hasn’t happened here. There has been too little too late. My final pay when I retired was much less than if I’d worked in Scotland and that impacted on my pension.

Where’s the early intervention?

There are calls for wider investment in preventative health in a bid to ease hospital waiting lists.

‘I am seeing my colleagues in hospital practice and emergency departments completely swamped with young adults who have obesity-related illness, chronic obstructive airways disease, type 2 diabetes,’ says Ray.

‘There is a demand there from people, who are not having their child health properly minded at an early stage, going on to have these long-term conditions, and they have a dependency on the health service.

‘The investments that we are seeing are all about adults, the waiting lists and four-hour targets. While those things are important, you have to look at the source. We would contend strongly that a good proportion of this is underinvestment in protection and prevention in modern healthy child programmes.’

Likewise, there are calls for greater investment in mental health after the failure to implement the Protect Life 2 strategy. ‘Apparently it needs ministerial sign-off. I don’t believe that,’ says Professor Heenan. ‘In other areas of the UK, they have undertaken interventions to bring suicide and self-harm rates down – ours are going up.’

Professor Heenan says: ‘The difficulty with mental health is it is the poor relation, so we’re treating the symptoms but not treating the underlying causes. We have no mental health strategy for NI, we have no mental health champion; we know because we are a post-conflict society we have more problems.

‘We are not working across the area of prevention in the community. The CAMHS waiting lists are atrocious. The message is “You really need to open up – you really need to see help” and they go and seek help and whoever the gatekeeper is says “Well actually it could be two years”. And two years is forever.’


Recruiting and retaining

CPs And what of the CP workforce? There was a 50% rise in numbers of nurses and midwives leaving the profession between 2013-14 and 2017-18 (Smyth, 2018c). This has been coupled with a cut in nurse training (The Irish News, 2018).

Consequently, the spend on employing nurses via nursing agencies grew from £10m in 2012-13 to £32m in 2017-18 (RCN NI, 2019) with nearly £12m exhausted on agency nurses from Scotland in 2017-18 (McDaid, 2018).

‘In health visiting, we rely on bank staff to keep services buoyant as we have quite a few staff coming up to retirement,’ says Sinead Toner, an HV from County Antrim and the NI chair of CPHVA NI. Unite estimates there could be up to 3500 vacancies in total across the NHS in NI (Unite, 2018a).

‘We have been getting additional numbers of HVs trained and into post – because we had that in place before the government left the building,’ says Janet. ‘In NI we still have a bursary for nurse training; in England they got rid of that. However, some nurses when they are qualified here are going to Scotland. HVs in Scotland are Band 7 – here they are generally Band 6.

‘School nursing is lagging behind and needs significant investment in training, development and increasing numbers. But we can’t do that unless we have a government who we can push those plans forward with.’

An absent government means healthcare leaders have no health minister to lobby. ‘We don’t have the people who will make the decisions about the big investment that is required,’ says Janet.

Although school nurses are meant to deal with child protection cases, there are insufficient numbers available to do this in primary schools, meaning HVs are performing this role, according to the CPHVA Executive.

Janet says this adds pressure: ‘All HVs are working to capacity and beyond – they have very busy caseloads.’

‘In England, health authorities are getting rid of HVs, downgrading them or giving them massive caseloads,’ says Sinead. ‘We are working towards smaller caseloads, and our situation in NI is better than England’s in this regard. But there are a lot of staff who are stressed out, partly because of the additional time it takes to do the job.’

Sinead, who became an HV after a career as a midwife explains that the situation has evolved gradually. ‘It’s a different job from when I came in 20 years ago. We did not have all that paperwork.’

Government breakdown

The NI Assembly was established at Stormont in 1998 after the Good Friday peace agreement, which signalled an end to the 30 years of violence known as the Troubles (NIA, 2019).

Since 2007, the main political parties shared power in the Assembly. But in January 2017, a dispute between the ruling parties, the Democratic Unionist Party (DUP) and Sinn Fein, erupted over payments to energy providers. First minister Arlene Foster (DUP) declined to step aside during investigations, deputy first minister Martin McGuinness (Sinn Fein) resigned and the NI Executive disintegrated.

In the election held soon after, no party gained a majority of seats. Two years later, no consensus has been reached on who should form a government (Kelly, 2019).

Pay issues 

Nurses, including CPs, have historically been paid less in NI than elsewhere in the UK and, since 2017, 1% public sector pay rises have been delayed (PA, 2018b; CSP, 2017). The latest is due at the time of publication. ‘We feel let down that we have not been brought into line with the rest of the UK. All we want is to be the same as everyone else,’ says Janet.

‘People do not like the lack of pay rise, especially when the Stormont executive themselves are still getting paid,’ adds Sinead.

MLAs’ pay was eventually slashed in November 2018 (with the final pay cut due at the start of 2019) from £49,500 to £35,888, almost two years after the executive folded, by the secretary of state for NI at Westminster, Karen Bradley (McCormack, 2018).

Unions rejected a proposed pay rise that would give a majority of NI nurses a 3% pay award because it still does not bring them in line with their UK counterparts (Kendall-Raynor, 2018).

Unite have been campaigning for NI healthcare workers to have their pay grades made the same as those across the UK, in line with Agenda for Change pay-scales. For example, a paramedic in NI gets paid £8000 less than they would in Scotland (Unite, 2018b).  

‘This is causing difficulties in the recruitment and retention of skilled and experienced healthcare workers and threatening a severe impact on the sustainability of local health services,’ says Kevin McAdam, Unite lead regional officer for health in Northern Ireland.

Waiting times Table

Morale and the future 

So how are CPs coping? ‘People are annoyed, but they do not kick off. When austerity came in, people were grateful to have a job,’ says Sinead.

Others say nurses are inherently able to deal with crises. ‘Nurses are amazing – they just keep going – in spite of everything else,’ says Janet.

‘For NI it is always going to be: “Well, we have had worse”,’ says Professor Heenan. ‘There is an apathy, acceptance of very poor standards. There is no one here saying: “This is outrageous – it would not happen anywhere else.” After two years of having no government, you need to step in with direct rule. You say: “We are not going to continue to pay you. That might sharpen your focus.” But Brexit has meant that the British prime minister and her cabinet are entirely consumed, and they do not have the bandwidth to start looking over here to us.’

‘The political impasse should not be used as an excuse for the destruction of our health service,’ asserts Kevin.

Secretary of state for NI Karen Bradley declined to comment, but a spokesperson for Westminster said: ‘Health is a devolved matter in NI. Restoring devolved government in NI at the earliest opportunity is the secretary of state’s absolute priority.’

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