Professor Rafael Bengoa sounds a little tired. The internationally renowned expert in healthcare transformation is in Belfast to attend NICON (the Northern Ireland Confederation for Health and Social Care) conference, where he is a keynote speaker.

He agreed to talk to The Doctor in a lunchbreak where there are obviously many other calls on his time – not least, the need to get something to eat.

And he must have anticipated the line of questioning. This month (October) marks the 10th anniversary of publication of what has become known as the Bengoa report. Called Systems, Not Structures: Changing Health and Social Care, it was praised for its clear-eyed dissection of the challenges facing the sector, and for achieving political consensus about the way forward – no easy feat in Northern Ireland. But a decade later, has that optimism translated into transformation?

‘There is a change of mood,’ he says. ‘At NICON, in the different sessions, everybody is completely engaged with the transformation, which was not completely the case 10 years ago. And what one feels, what one can see, is that there are many local experiences that are beginning to pop up around what’s generally called the shift left [a model moving focus, care and resources from acute hospitals into primary, community and preventive settings] and they are beginning to take hold, which is very encouraging. What I’m seeing is that we’re beginning to move forward in a structured way.’

As well as advocating the shift left, the Bengoa report called for a neighbourhood health model (with a focus on GPs), better integration between health and community care, and a consolidation of specialist services – recognising that centralising certain specialties on a smaller number of sites is better for safety and quality.

It’s a similar model that’s been advocated in other systems – for example, in England’s Ten Year Health Plan – but is clearly easier said than achieved. It also warned – in a section called The Burning Platform – an unassailable case for change – that the system would become unsustainable without radical transformation, predicting disastrous waiting lists, GPs returning their contracts, and staff burnout. 

Precious little in the way of centralising services has happened in Northern Ireland, and it continues to be a difficult area (apart from anything else, a row over rationalising emergency general surgery recently contributed to the resignation of health minister Mike Nesbitt.) And while there have been some moves towards a neighbourhood health model, access to GP services remains tough, practices have handed back their contracts in record numbers and waiting lists for secondary care treatment remain the worst in the UK.

Today, Prof Bengoa says that, while the need for rationalisation became the main ‘frame’ of discussion around the report, for him, other issues are where the big wins can come. ‘What we were saying 10 years ago is that you have to start moving forward on integrated care because that’s where the savings are from, and prevention is where the savings are, and doing more on reducing waste.

'What we’re seeing now is that leaders at the NICON conference are beginning to show that they can begin to reduce waiting lists in different areas, and that is very energising. I think people are beginning to see that they can share and scale up some of these initiatives, and if they are scaled up, one can start seeing that transformation is taking hold.’

Asked why implementation of the report hasn’t made more progress, Prof Bengoa sounds resigned. ‘You can’t underestimate what has happened across all our countries with the pandemic,’ he says. ‘That has occupied five years. Also, Stormont has had its headaches [including lengthy suspensions of devolution] and its problems politically during these years. So, let’s say there haven’t been at the policy level all the elements that one needs to do transformation.’

Despite the influence of these external factors, Prof Bengoa is clear that successful transformation depends on engagement of health professionals, including doctors. ‘One has to bring doctors and nurses on board, because otherwise you’re going to have unnecessary resistance,’ he says. But he cautions: ‘I think one has to stop thinking there’s one Big Bang moment, there’s one Bevan moment, in which he sort of said, “okay, we’re going to do a universal free at the point of care policy”. This is about consistent change and innovation, bottom up, engaging people across the board.’

He also has a message for politicians. ‘Ten years ago, five political parties engaged with us as a panel, and we agreed on a diagnosis, we agreed on some principles that would drive us, and we all agreed as a political group across Stormont to move this agenda forward. I think it would be convenient – after the [2027] election – for this to happen again. It would be interesting if the political parties could say, “look, it’s time for us to engage again into something that’s really running above our political parties, like we did 10 years ago. It would be great if that could happen again”.’

Belfast surgeon Professor Mark Taylor sat on the small panel behind the Bengoa report – and it’s probably fair to say that he’s devoted much of his professional life since to ensuring it is implemented. He is Northern Ireland’s first regional clinical director for elective care – a role that in the [Tony] Blair years would probably have been called ‘waiting lists tsar’.

He spoke to The Doctor last year about his determination to end the ‘national shame’ of lengthy waits for treatment, and today he’s confident that there has been some progress. He describes a range of work that he sees as carrying out the report’s aims, including neighbourhood federations, elective surgery centres, the public health ‘conversation’ This is Our Health, and the Encompass electronic health record. ‘All of these different facets are actual implementation of what was originally in the [Bengoa] report,’ he says.

There’s also good news on waiting times, he adds. ‘The official statistics are showing a fall in those waiting for first outpatient appointments. That’s the second consecutive fall. In other words, there were 15 years of rising demand, rising waiting lists for outpatients, and for the second year in a row there’s been a fall, and that’s continuing. Every single day people are added to that waiting list, and yet we’ve been able to deal with the rising demand but also reduce the overall wait.’

There’s also a ‘definite reduction’ in waits for named procedures, such as colonoscopy, he adds. ‘Initially the [plan] was to get below four years, but we’re down to two years, and actually, by the end of this year we’ll be down to 26 weeks. Other named procedures – hip replacements, knee replacements, hernias, gallbladder – all of these are on the right trajectory.’

Part of this has been down to modernising outpatient processes and improving the interface, and relationships, between primary and secondary care, he says. But he accepts that, from a patient perspective, it’s hard to see that anything is changing.

‘A lot of the changes that have been taking place – it’s hard for the public to feel them, but that will happen in the fullness of time. There’s definitely a positivity in the public in that they’re seeing waiting lists change, and they’re feeling a sense of urgency.’

It’s still tough for doctors and other healthcare professionals, he concedes. ‘In terms of staff, we do still have moral distress – when you’re seeing people that you know should have been seen sooner, that does lead to clinician distress. It’s fair to say we’ve still a large hill to climb, but we’re definitely starting that trajectory and we’re in the foothills of that.’

If Prof Bengoa sounded tired, and Prof Taylor cautiously optimistic, perhaps the best word for Alan Stout is frustrated. As a Belfast GP, he also sat on the Bengoa panel, hoping it would lead to better outcomes for his patients and a better healthcare system for doctors to work in. Now, as chair of the BMA’s Northern Ireland council, he is still waiting for that to happen.

‘It’s intensely frustrating,’ he says, reflecting on the 10th anniversary of the report. ‘We’re seeing in live time all the predictions that were made, everything that was listed in the “burning platform” that was in the report has come true.’

The one exception, he adds, is that the report warned that health would eventually take up 80-90 per cent of Northern Ireland’s block grant. ‘We don’t have anywhere near that, but we’re continuing to do what we’ve always done, and hence we’re seeing the real crisis unfold in front of us.’

The entry points to healthcare define that crisis, he says – people have to wait for GP appointments, and emergency departments are congested. ‘People’s experience, when they need healthcare, which can often come on very suddenly, is not good at all,’ he says.

He was quite optimistic when the report was first published. ‘We actually had a report that gave us a roadmap. And the second reason I was optimistic was that – almost unique in Northern Ireland – we had broad political support. But shortly afterwards the executive collapsed, and then collapsed again, and the early optimism, particularly around the political leadership evaporated very quickly.’

Writing the report was reasonably straightforward, he says (even if it did involve a big time commitment for the panel members). But implementation has proved to be anything but. He says Prof Bengoa warned that ‘implementation incompetence’ would be the downfall – and that he was right.

While Dr Stout acknowledges that there have been pockets of improvement, including on waiting lists, he is concerned that the focus is wrong. ‘We’ve gone for the longest waiters as opposed to the highest priority. We’re not addressing cancers and red flags – only 28 per cent of our patients meet the 62-day target for starting treatment from day of referral, and that’s shocking.’

He wants to see the workforce prioritised – and given that at the time of writing all four branches of practice are currently in dispute with the Northern Ireland Executive over pay and conditions, it would seem there’s a way to go.

‘We cannot lose our workforce, either figurately in terms of how they think and their commitment, but also physically in terms of them just up and leaving. And we’re seeing that. We need to be competitive in what is a worldwide market for workforce, and we’re not. We’re about to see waves of industrial action over a simple pay uplift, never mind addressing pay restoration, so that would be the first thing.’

His other priorities include improving confidence in the public, for example by improving access to GPs and to emergency departments. He also wants a good, responsive community mental health service, and a greater focus on cancer treatment.

But it’s not all doom and gloom. ‘There’s an inkling of hope. There’s a lot of talk UK-wide about the neighbourhood model, and I think Northern Ireland has an opportunity to do it better than anywhere else because it’s been very much focused on it being GP-led and with GPs integrally involved. If done correctly, it quite clearly is the right direction of travel. We’ve got to make sure we commit to it. That’s the key.’