Systems, Not Structures: Changing NI Health and Social Care
Eight years after 'Systems, Not Structures': Has Northern Ireland's healthcare reform stalled?
By Dr Richard Dune
Image by insidecreativehouse via Envato Elements
In 2016, Northern Ireland’s health and social care system was at a crossroads. Professor Raphael Bengoa's 'Systems, Not Structures' report outlined a bold vision for transforming the region’s health service. The plan was simple in theory: move away from a hospital-centric, reactive model to one that focuses on community-based care, prevention, and the better management of chronic conditions.
The report struck a chord across the healthcare landscape, providing a clear and urgent case for reform. Yet, eight years later, Northern Ireland’s health system faces the same structural challenges, with many of the key recommendations only partially implemented. So, what happened, and why has the transformation been so slow?
Image by fauziEv8 via Envato Elements
The vision - What 'Systems, Not Structures' promised
When the report was released, it painted a dire picture: Northern Ireland’s health system was unsustainable, overly reliant on acute hospital care, and unable to meet the growing demand driven by an ageing population and rising health inequalities. The goal was clear: shift resources toward community and primary care, improve preventative healthcare and address the stark health inequalities across the region.
The plan's core was the development of Accountable Care Systems (ACS), which would foster integrated, patient-centred care across community, primary, and secondary health services. The report also introduced the Triple Aim framework, which focused on improving patient care, enhancing population health, and reducing per capita healthcare costs.
Progress or paralysis? The reality from 2016 to 2024
Despite the promising vision, the transformation has been painfully slow. Political instability, including the collapse of the Stormont Executive, left a leadership vacuum just when decisive action was most needed. Without sustained political commitment, the healthcare reform agenda stalled.
Northern Ireland has seen some progress in implementing the recommendations. Establishing surgical hubs to tackle waiting lists is a notable success, and Integrated Care Partnerships (ICPs) and GP Federations have been rolled out in parts of the region. However, these successes have been overshadowed by budgetary constraints and the pressures of short-term crisis management, particularly following the COVID-19 pandemic.
The pandemic significantly affected healthcare reform efforts, diverting resources to emergency response. Recovery from the pandemic has further strained an already overstretched system, increasing waiting lists and demand on emergency care services.
Image by LightFieldStudios via Envato Elements
Image by YuriArcursPeopleimages via Envato Elements
Workforce challenges and healthcare inequalities
A critical issue raised in the 2016 report was the workforce crisis - a problem that still persists. The system's reliance on locum and agency staff has become a costly crutch, with workforce shortages leading to burnout and poor staff morale. The lack of long-term workforce planning has undermined efforts toward a sustainable, patient-centred care model.
Health inequalities also remain a significant issue, with outcomes in deprived areas continuing to lag behind more affluent regions. The vision of bringing care closer to communities through GP-led services has been stifled by funding cuts and the closure of GP practices, further widening the gap in healthcare access across the region.
Resistance to change - Centralisation and public sentiment
Another core recommendation of the report was the rationalisation of hospital services - consolidating specialised care to create centres of excellence while shifting non-urgent services to community settings. Although the centralisation of some services has progressed, it has been met with public resistance, particularly in rural areas where patients now face longer journeys for specialist care.
For political leaders, closing or downgrading hospitals is far from a vote-winner, contributing to the slow pace of reform. The balance between maintaining local services and creating a more efficient, sustainable system remains politically fraught.
Image by YuriArcursPeopleimages via Envato Elements
Image by iLixe48 via Envato Elements
Bengoa’s 2024 revisit - A reality check
In 2024, Professor Bengoa returned to Northern Ireland to assess the progress made since his 2016 report. His conclusion was sobering. While there have been some advancements, major struggles remain in balancing the immediate pressures on the health system with long-term reform needs.
Mike Nesbitt, Northern Ireland’s Health Minister, has acknowledged the need for radical decisions but faces the same budgetary and political constraints that have dogged the system for years. Nesbitt’s promise to be the man who makes the "difficult calls" echoes the urgency of the moment - but the window for meaningful action is closing.
The road ahead - Time for bold decisions
Eight years after the publication of Systems, Not Structures, Northern Ireland’s health and social care system still faces the same crossroads. Without bold leadership and sustained financial investment, the vision laid out in 2016 will remain a distant aspiration rather than a reality. The healthcare system, its workforce, and most importantly, its patients cannot afford further delays.
The next steps are clear: prioritise workforce development, scale up successful innovations, and commit to the long-term transformation needed to deliver patient-centred care. The political will to make difficult decisions and sustained financial backing will be crucial to moving from slow progress to true reform.
Image by iLixe48 via Envato Elements
Image by Pressmaster via Envato Elements
Meet regulatory demands with ComplyPlus™
At The Mandatory Training Group, we provide expert guidance to help healthcare providers meet compliance requirements. Contact us to learn how ComplyPlus™ can support your organisation in navigating Northern Ireland’s evolving healthcare landscape.
This blog was originally published in 2016.
The vision - What 'systems, not structures' promised
Image by fauziEv8 via Envato Elements
When the report was released, it painted a dire picture: Northern Ireland’s health system was unsustainable, overly reliant on acute hospital care, and unable to meet the growing demand driven by an ageing population and rising health inequalities. The goal was clear: shift resources toward community and primary care, improve preventative healthcare and address the stark health inequalities across the region.
The plan's core was the development of Accountable Care Systems (ACS), which would foster integrated, patient-centred care across community, primary, and secondary health services. The report also introduced the Triple Aim framework, which focused on improving patient care, enhancing population health, and reducing per capita healthcare costs.
Progress or paralysis? The reality from 2016 to 2024
Image by LightFieldStudios via Envato Elements
Despite the promising vision, the transformation has been painfully slow. Political instability, including the collapse of the Stormont Executive, left a leadership vacuum just when decisive action was most needed. Without sustained political commitment, the healthcare reform agenda stalled.
Northern Ireland has seen some progress in implementing the recommendations. Establishing surgical hubs to tackle waiting lists is a notable success, and Integrated Care Partnerships (ICPs) and GP Federations have been rolled out in parts of the region. However, these successes have been overshadowed by budgetary constraints and the pressures of short-term crisis management, particularly following the COVID-19 pandemic.
The pandemic significantly affected healthcare reform efforts, diverting resources to emergency response. Recovery from the pandemic has further strained an already overstretched system, increasing waiting lists and demand on emergency care services.
Workforce challenges and healthcare inequalities
Image by YuriArcursPeopleimages via Envato Elements
A critical issue raised in the 2016 report was the workforce crisis - a problem that still persists. The system's reliance on locum and agency staff has become a costly crutch, with workforce shortages leading to burnout and poor staff morale. The lack of long-term workforce planning has undermined efforts toward a sustainable, patient-centred care model.
Health inequalities also remain a significant issue, with outcomes in deprived areas continuing to lag behind more affluent regions. The vision of bringing care closer to communities through GP-led services has been stifled by funding cuts and the closure of GP practices, further widening the gap in healthcare access across the region.
Resistance to change - Centralisation and public sentiment
Image by YuriArcursPeopleimages via Envato Elements
Another core recommendation of the report was the rationalisation of hospital services - consolidating specialised care to create centres of excellence while shifting non-urgent services to community settings. Although the centralisation of some services has progressed, it has been met with public resistance, particularly in rural areas where patients now face longer journeys for specialist care.
For political leaders, closing or downgrading hospitals is far from a vote-winner, contributing to the slow pace of reform. The balance between maintaining local services and creating a more efficient, sustainable system remains politically fraught.
Bengoa’s 2024 revisit - A reality check
Image by iLixe48 via Envato Elements
In 2024, Professor Bengoa returned to Northern Ireland to assess the progress made since his 2016 report. His conclusion was sobering. While there have been some advancements, major struggles remain in balancing the immediate pressures on the health system with long-term reform needs.
Mike Nesbitt, Northern Ireland’s Health Minister, has acknowledged the need for radical decisions but faces the same budgetary and political constraints that have dogged the system for years. Nesbitt’s promise to be the man who makes the "difficult calls" echoes the urgency of the moment - but the window for meaningful action is closing.
The road ahead - Time for bold decisions
Image by iLixe48 via Envato Elements
Eight years after the publication of Systems, Not Structures, Northern Ireland’s health and social care system still faces the same crossroads. Without bold leadership and sustained financial investment, the vision laid out in 2016 will remain a distant aspiration rather than a reality. The healthcare system, its workforce, and most importantly, its patients cannot afford further delays.
The next steps are clear: prioritise workforce development, scale up successful innovations, and commit to the long-term transformation needed to deliver patient-centred care. The political will to make difficult decisions and sustained financial backing will be crucial to moving from slow progress to true reform.
Meet regulatory demands with ComplyPlus™
Image by Pressmaster via Envato Elements
At The Mandatory Training Group, we provide expert guidance to help healthcare providers meet compliance requirements. Contact us to learn how ComplyPlus™ can support your organisation in navigating Northern Ireland’s evolving healthcare landscape.
This blog was originally published in 2016.
About the author
Dr Richard Dune
With over 20 years of experience, Richard blends a rich background in NHS, the private sector, academia, and research settings. His forte lies in clinical R&D, advancing healthcare tech, workforce development and governance. His leadership ensures regulatory compliance and innovation align seamlessly.
About the author
Dr Richard Dune
With over 20 years of experience, Richard blends a rich background in NHS, the private sector, academia, and research settings. His forte lies in clinical R&D, advancing healthcare tech, workforce development and governance. His leadership ensures regulatory compliance and innovation align seamlessly.
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