The Big Difficult Decisions needed to transform health

Northern Ireland’s new Health Minister, Robbie Butler, has the unenviable task of leading his department in the jaws of an election. He has come to be in the role after party politics derailed the decision-making of his predecessor, Mike Nesbitt. Is it time to look at whether something as fundamentally important as our health service should be separated from politics?

Health currently accounts for more than half of the total Northern Ireland budget. Even with a budget of almost £8.4 billion, it is overspending by roughly £2 million per day, driving a total projected budget deficit of between £800 million and £1 billion.  Welcome to your inheritance, Minister Butler.

As the new term in the Assembly got underway, we saw photocalls aplenty. The new Minister and MLAs are getting buffeted by requests from a range of equally compelling causes, each laying out their stall for prioritisation in election pledges. We’ve seen cancer services, end-of-life hospice care, and neurology services, among others, on the steps of Stormont in just a couple of days. Each is also typically outlining the need for investment in potentially life-changing or life-saving services, in order to do more, better or faster. 

Back to point one: we’re massively overspent, more money is not an option.

And this brings us to the Big Difficult Decisions (BDD) needed to change the status quo.  Heading into an election is never a good time for the BDD. Not vote-winning.

So, let’s take a look at the structures in place that Minister Butler is now going to hold tight to. These exist and, believe it or not, progress is being made. Turning this oil tanker around is slow and hard to discern.

There are three themes driving change: Stabilisation, Reform and Delivery. These were laid out in a three-year strategic Reset Plan in December 2024. 

Stabilisation is about driving financial efficiencies, in every area and at every level. In its latest update on progress against this at the end of August, the Department of Health reported that it had delivered savings of over £300million in the 2025/26 year and £200m in 2024/25. In typical good-news/bad-news style, this announcement also stated that the HSC had been tasked with ‘delivering 4% cash releasing and efficiency savings’ this financial year: 12% over three years. 

One of the big target areas for delivering this is cutting the over-reliance on expensive agency and locum staff (freelancers who earn a higher hourly rate than contracted staff), which cost our health service £382 million in 2024/25.

However, another key to stabilisation is making rates of pay for all our health and social care workers attractive and fair. Valuing the workforce in Northern Ireland is critical. Within hours of him taking up the Ministerial portfolio, the Royal College of Nursing warned Mr Butler that they intend to ballot for strike action. Other cornerstones including GPs and Community Pharmacies have also been in negotiations for funding to stabilise their services.

What is the Neighbourhood Model?

Looking to more creative solutions, at the heart of the Reset Plan is the term ‘Neighbourhood Model of Care’ – aimed at bringing care closer to home and freeing up acute hospital beds and taking pressure off GPs and Emergency Departments. There’s no point in revisiting the reality of these services at the minute – they are well documented.  Again, underscoring that things drastically need to change.

We’re going to hear a lot more about the Neighbourhood Model in coming weeks and months. It’s starting to come together. Integrated Neighbourhood Teams (INTs) are a model used in NHS England, bringing together multi-disciplinary professionals, including primary care, hospital care, community care, mental health, social care, and voluntary sector organisations to deliver care for a group of patients in their area. Getting this in place will be a big-ticket item for Minister Butler, but again, this will be just the beginning, and impacts will take a while to become evident.

One of the other commitments in this Reset Plan is a greater emphasis on prevention and early intervention – getting ahead of acute illness is a really good idea, not just to keep us well but to reduce the burden on health services. INTs would play a part in this, proactively identifying patients who may need additional support to prevent later ill-health and hospital care, supporting them to live well in the community. 

Going one step further, Minister Nesbitt said on a number of occasions that, as a population, we need to take more responsibility for looking after our own health. Service reform will also involve a mindset shift for all of us, placing less reliance on a stretched health system to pick up the pieces of our own poor lifestyle choices. Under Minister Butler, we may see more health promotion messaging nudging us to eat healthier and move more as a bare basic.

As a dual carrot and stick approach, new legislation will support healthier choices – like the Tobacco and Vapes bill, the current consultation on restricting the promotion of deals on unhealthy foods high in fat, salt and sugar. A ban on sunbeds has been talked about, but won’t happen in this mandate, even though skin cancer accounts for a third of all cancers diagnosed here. Minimum unit pricing on alcohol failed to get over the line earlier this year. Excessive alcohol is still at the root of a lot of our chronic health issues and extended hospital stays. This was another example of a BDD being derailed by politics.

Tackling waiting lists was built into the Programme for Government when the Assembly was restored in early 2024 and the NI Executive ring-fenced £165m to achieve it. Again, progress has been made on this. However, as an ever-growing organism, as those who have been waiting are seen, more new patients join the queue at the bottom. It’s like cutting one of the heads off the mythical hydra and seven more grow back.

The Reality of Reform

Back to the bird’s eye view – this is an extremely complex set of challenges, and a major overhaul is needed.  And so, to Bengoa... 

The Bengoa Report will be 10 years old in October.  It stated that reform is about Systems Not Structures – a whole system approach, shifting away from a hospital-centric model to a community-based integrated prevention service – basically what we’re now seeing being brought forward. 

Apart from one pain-point – in shifting some resources closer to local communities, it’s also necessary to centralise some of the more specialist services. This means moving some services away from smaller hospitals and putting them together in centres of excellence which can attract top doctors and nurses, with full clinical support.

This is what brought Robbie Butler to the Ministerial role.  Even though the thoroughly considered decision to withdraw emergency general surgery from the Causeway Hospital in Coleraine aligned with Bengoa’s structural reform, it became a political football and caused local outcry.

Faced with this immediate dilemma, days after his appointment, Minister Butler announced the formation of an Independent Reconfiguration Committee, an expert advisory committee to provide advice on major changes to health and social care services in Northern Ireland. He stated that this will ‘advise but not decide’, so the BDD will ultimately still be political, but with an added safety net.

In the meantime, Minister Butler has put the Causeway decision on ice. The BBC reported that the new Independent Committee had been in the planning before things came to a head and was just pending the appointment of a Chair. This is yet to be revealed. Meanwhile, cross-party politicians have taken the political opportunity to accuse the new Minister of ‘kicking the can down the road’ and immediately labelling him a ‘caretaker minister’.

Professor Bengoa will be back in Northern Ireland for the health service’s major NICON conference in October. Minister Butler will take comfort from knowing that there is good continuity in health service leadership from Bengoa’s report 10 years ago. It involved Professor Mark Taylor (surgeon and waiting lists guru), Dr Alan Stout (BMA voice of NI GPs) and Sean Holland, newly appointed as Chair of the NI Social Care Council (NISCC) who was the former Chief Social Worker for Northern Ireland. This continuity from the inside is important to keep moving change forward.

Minister Butler is now at the helm of the slowly turning oil tanker. If he keeps his eye on the horizon, he will be able to spot the slow and steady movement in a different direction.  Whether he will be able to hold that course in these particularly choppy political waters remains to be seen.

First though, he’ll be in front of the health committee next week, being quizzed on his department’s approach to the rapidly approaching assault of winter pressures.  Keep your hand on the tiller, Minister. Full steam ahead.