Consultant surgeon David Vass might not be wearing a cape but there is little doubt he and his colleagues deserve to be treated as heroes.

Doctors across Northern Ireland’s entire health and care system – and that very much includes GPs – are playing a leading role in the biggest sustained effort to bring down waiting times since the start of devolution or even before.

As has been well rehearsed, waiting lists are a huge issue in Northern Ireland, with thousands languishing on them for years, some even dying before they get that treasured first outpatient appointment, let alone the actual treatment.

The Doctor has been reporting on this for some time – but this year it feels a bit different. Tackling waiting lists is a priority in the Northern Ireland executive’s programme for government and £215m has been allocated for elective-care initiatives in the current financial year. This financial boost – although obviously not nearly enough – is all the more remarkable given the dire fiscal straits in which the executive finds itself and demonstrates that the terrible state of elective care is cutting through to those in charge.

The Doctor has published interviews with the Professor Mark Taylor, the surgeon charged with spearheading efforts to cut waiting lists, and with Mike Farrar, the veteran health service leader who is head of the health and care system and permanent secretary of the Northern Ireland department of health. It has also met and spoken to those on the front line who are trying to translate policy into practice.

Briefly, the additional funding covers three main categories: £85m for red-flag and time-critical care; £80m to build up capacity; and up to £50m to tackle the backlog. A plan for implementation published in May, sets out in detail how this money is to be spent – and the outcomes it should achieve.

As lead for hepato-biliary surgery at the Belfast Trust, Mr Vass has been instrumental in achieving some of the initiative’s earliest successes, which has seen a dramatic fall in numbers of people waiting for gallbladder surgery.

‘One of the problems with gallbladder surgery is that these patients are tomorrow’s hospital admissions because they can develop issues with gallbladder disease such as pancreatitis, cholecystitis and stones of the bile duct, and often that requires significantly more investment in treatment,’ he explains. ‘One of the things I’m keen to do to prevent that is get these patients managed at an earlier stage, so we’ve done that.’

A series of initiatives contributed to a 40 per cent fall in numbers waiting for gallbladder surgery. These include the use of mega clinics – a one-stop shop where people on the waiting list are invited in to see a surgeon and the wider clinical team to determine the best way to manage them. Each clinic – held on a Saturday – has a list of about 40 patients, who see a surgeon first to make sure they still want the operation, and if they do, the anaesthetic consultants do a full pre-operative assessment, and they have blood tests.

At the end of the day, the team discusses the list and works out a plan for them, depending on whether they need further investigations or are ready to be operated on. Other considerations are whether they can be treated at the Mater Hospital site, or the City Hospital for more complex cases.

‘One of the things we did was create a database with each patient’s name, their diagnosis and their availability – do they need a week’s notice, two weeks’ notice? – with a colour code, so red is that the patient is removed from the list, yellow is that they need further investigations and green is that they are good to go,’ explains Mr Vass. 'This brings clarity and helps with scheduling.

'Because staff are working more than their usual hours, they are paid for doing this from waiting-list initiative money but it is still hugely generous of them to give up their Saturdays.

‘In our specialty we already do one weekend in four, so this does have an impact on family life as well,’ adds Mr Vass. ‘We would like to do it in the working week but unfortunately that would displace other sessions.’

It is difficult for patients who have usually been waiting many years to get to this point, but it is also hard for staff, he adds. ‘People are doing this out of their job-plan time, out of their contracted time. The challenge is how do you do that when you have a set number of consultants and a set number of sessions, particularly in our trust, where most of our work is regional cancer work. It’s very difficult trying to do the biliary work in addition to that – being expected to deliver that and on the backlog is a challenge.’

Validation of the waiting lists – that is, checking that people need to be on them, or whether they need any further investigations before surgery – has been another key contributor in tackling the backlog. This involves looking at people’s medical records and conducting telephone reviews where appropriate. Some of this is being done by retired surgeons, Mr Vass explains, and patients might be referred to the mega clinic or for investigations.

‘One of the problems is that people are waiting so long, we’ve had to organise further scans just to make sure. It’s a bit difficult to operate on patients with a scan that’s six years out of date.’

There has been a good response from patients, he says. ‘I think they’re generally very happy to get it done. In the mega clinics, we were able to provisionally pencil in a date, so they felt something was actually happening. Before the mega clinics, there was no obvious end game for the patient, but now they feel they’re actually going to get their operation.’

Waiting list validation and mega clinics are only two ways that the health service in is tackling waiting lists. Elective care centres – are developing throughout Northern Ireland, aimed at patients who need surgery and might require an overnight stay.

The Doctor visited the overnight elective surgery unit at Belfast’s Mater Hospital, which carries out procedures in ENT, general surgery, gynaecology, breast, and urology, and was shown round by Sharon Adamson, initially head nurse for the hub, but now manager for surgical services with the Belfast Trust.

‘It’s multi-specialty and aimed at long waiters,’ explains Ms Adamson, a powerhouse of a woman who is impressively enthusiastic about what the trust is achieving. ‘We’ve treated more than 6,000 patients since it opened [in 2023], and we’re hoping to increase this as consultants become more confident in the service,’ she says. ‘We’ve had good buy-in from consultants – we started small and are growing incrementally – and it’s a good example of a multi-specialty unit.

Surgical hubs like this aren’t a magic bullet and they aren’t suitable for everyone, for example, patients more at risk of needing ICU back-up. There are also – inevitably – resource issues, including access to theatre time and staff.

But Ms Adamson adds: ‘We’re starting to see a bit of momentum, and that’s good news for everyone.’

GPs are at the sharp end of Northern Ireland’s waiting-list crisis. They are the ones who are referring patients, all the while knowing that it is likely a futile exercise.

‘Patients are saying to their children, don’t buy me a Christmas present, don’t buy me a birthday present, pay for me to see a consultant,’ says Frances O’Hagan, chair of the BMA Northern Ireland GPs committee and a GP in Armagh.

‘When I’m doing a referral, in practice unless it’s a red-flag referral, 90 per cent of the time the patient asks how long it’s going to be, and then when you say “years” they ask how much it will cost to go private, and I know they can’t afford it.’

Conor Moore, a GP in a neighbouring practice, looks despairing as he agrees. ‘We have families clubbing together to fund MRIs – they’re funding things they can’t afford. The system is dire, it’s broken, it’s in tatters, and money isn’t being spent in the right place to provide any solutions.’

In a way, he can’t quite believe that the populace isn’t more outraged by this. ‘There’s a sense that [people] feel it’s acceptable, whereas in the past it just wasn’t. Look at France – if there’s a change to pension systems, everybody’s out in the streets, whereas locally if I refer a patient to a urologist with a routine problem, that’s seven years. I feel at risk even professionally, because if I know that something routine is going to take seven years, should I refer everything urgently, then everything becomes urgent? There’s a big moral injury to people who are putting referrals in and knowing their patient is never going to be seen.’

Dr O’Hagan has seen this from a personal perspective too. ‘I watched my own mother languish on a waiting list to get her hips done for years, then we said enough is enough and clubbed together as a family and took her to Dublin – and Mummy can now walk again,’ she says. ‘She lives rurally and she can drive again. At 82, she now has her life back, but only because we as a family clubbed together to pay for it.’

GPs across Northern Ireland are helping to lower waiting lists – by reducing the number of patients who need to go on them. Impressive initiatives, many of them grassroots-led, are ensuring that patients who need treatment can get it closer to home, without troubling the hospital sector.

For example, the GP Federation General Practice Elective Care Service – where practices can refer patients to a GP with a special interest in several areas, including gynaecology, dermatology and minor surgery – is already ensuring that thousands of patients never make it to secondary-care waiting lists. Since 2018, more than 80,500 patients have been seen by the service.

Ursula Mason, a GP at Carryduff Surgery, near Belfast, and chair of RCGP Northern Ireland, was instrumental in setting up the gynaecology pathway. Patients can be referred for long-acting, reversible contraception, expert HRT treatment, heavy menstrual bleeding (in under-45s) and for pessary replacement.

Currently, patients referred routinely to Belfast Trust for gynaecology for a first appointment will wait 61 weeks. A GPECS referral, on the other hand, will have a wait of between two and 12 weeks for the eight practices that offer it.

‘It’s a very flexible service and it’s popular with patients and practices,’ Dr Mason explains. ‘It’s also very cost-effective.’

Another advantage is it allows GPs to use expanded skills, improving job satisfaction, she adds, although concerns remain about sustainability of funding to provide the services, as well as having enough GPs available to participate.

GPs are also grouping together less formally to offer specialist services to their communities. In Armagh, for example, three practices coordinate on a system that brings secondary-care expertise to their child patients once a month, without the need of a secondary-care referral. The system started before the pandemic (and the consultant used to attend in person) but now happens online.

Essentially, GPs will ‘refer’ any child they feel would benefit from the advice of a paediatrician, and the case will be presented to the consultant, who can then ask the GP relevant questions, such as family background, explains GP partner Frances O’Hagan. ‘Then he’ll say, “have you tried this, or that?” and over time we’ve got to know what he’ll ask, so we’ve already done it.’

The consultant might then suggest a course of action for the GP to take, including further investigations (the results of which will then be fed back to the consultant) or will want to see the child in person.

‘The parents absolutely love it – the feedback’s been amazing,’ says Dr O’Hagan. ‘And I don’t think I’ve referred one child [to the secondary care waiting list] since it started.’

Again, however, achieving sustainable funding to keep this initiative going, and potentially expanding it to others, is always going to be the issue. ‘It’s a success story,’ says Armagh GP Conor Moore. ‘But part of the reason it works is that there’s funding for it because it’s funded through public health very much as a pilot. I know other areas have tried to get it up and running, but you need funding for the extra work we have to do to get the information and prepare the case. If we had more funding, we could do so much more.’

Read the other two features in this series on waiting times in Northern Ireland:

Read More to give

Read The War on Waits