Slow-building crisis in North’s health system keeps excess deaths ‘off the radar’, says senior doctor

When he started working in Northern Ireland’s hospitals, Russell McLaughlin had never heard of a trolley wait. It was the mid-1990s and the then junior doctor didn’t know what burnout was either.

He hadn’t heard of the phrase. That year, 1994, was “a bad year in the Troubles” but his work was “mainly bread-and-butter work and our hospitals worked”, he said.

“Patients went to wards, patients got discharged. We didn’t have the dysfunction we have now,” he said.

Based in the Royal Victoria Hospital in Belfast and one of Northern Ireland’s most senior consultants, McLaughlin took over last March as the Northern Ireland head of the Royal College of Emergency Medicine (RCEM), a UK professional body and charity representing doctors in emergency departments. It is a role he juggles with his day job.

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‘Once you have patients regularly and at volume waiting beyond five hours, you start to see an increase in things going wrong’

—  Russell McLaughlin

A fortnight ago, a WhatsApp message forwarded by a college member posed a question that made him stop and compare then, when he was a junior doctor, and now: is the death rate for patients delayed in Northern Ireland’s emergency departments in 2022 higher than the Troubles in its worst year?

Using what McLaughlin describes as “robust” research on excess deaths – essentially deaths that are unexpected – the medical data was compared with statistics from an archive on conflict-related fatalities.

“Once you have patients regularly and at volume waiting beyond five hours, you start to see an increase in things going wrong,” he said.

“It’s not just a quality issue, it’s a safety issue as well and that increased delay is associated with harm in our emergency departments. I have personal experience and feedback from colleagues across this region of patients, particularly elderly patients, waiting for days.”

Opening up his laptop, he scrolls through rows and rows of figures; the data, he says, is “really quite stark”.

“In very simple terms, there is strong evidence that indicates that in 2022, 1,434 people died as a result of delays in Northern Ireland’s emergency departments,” he said.

Lost Lives, the seminal volume chronicling all deaths during the Troubles, lists 497 fatalities in 1972, the worst year of the three-decade conflict. McLaughlin points out “the amount of political, governmental and social effort” it took to move from the number of deaths in that year to now.

‘...if we don’t take action maturely, impartially and move forwards, then we can expect to lose 1,400 people next year and the year after, because the situation is not going to improve on its own’

—  Russell McLaughlin

“We have thankfully had a huge improvement and a move away from that terrible time. What the health system needs is an equal effort,” he said.

“We need that political maturity, that political pressure, we need governmental action and we need also societal engagement to accept that if we don’t actually wake up to our health crisis right now, and if we don’t take action maturely, impartially and move forwards, then we can expect to lose 1,400 people next year and the year after, because the situation is not going to improve on its own.”

McLaughlin’s frustration with Stormont’s two-year deadlock is palpable. This week, yet another effort at restoring the North’s powersharing Executive failed and public sector workers took unprecedented strike action over pay.

As the head of a professional body, McLaughlin is not free to express his political views.

“I can’t lean one way or the other. But it’s not overly political to say you need a government,” he said.

More than 25 years on from the landmark Belfast Agreement that underpins Northern Ireland’s peace, the North’s hospitals have consistently recorded the worst waiting lists in the NHS.

McLaughlin’s concern is that amid the stalemate, a crisis is happening “under the noses” of politicians at a time when “our society has almost become immune” to it.

“I suppose the point is that we’re losing a significant volume of patients every year and it’s off the radar,” he said.

“Any excess death is a tragedy for the individual and the family but once you get into this level of statistics, you’re looking at systemic failure. Those deaths in 1972 were individually reportable and terrible events.

“What we have in health now is a much lower profile, slow-burn crisis.”

Despite multiple independent reports (seven at the last count) recommending an overhaul of how Stormont’s health service is set up, much-needed fundamental reforms have not happened.

“I think, and it’s well publicised, that the ability to make service structural change at volume within the health service in Northern Ireland is always tinged with politics,” said McLaughlin.

“Therefore, we have failed to implement external reports – and those were times we did have a government in place.

“But if we don’t have a functioning government, we can’t move forwards. One of the key functions of that government would be to listen to clinical staff who hold the answers to many of the challenges.”

Spiralling waiting lists are not confined to Northern Ireland. In the Republic, 23 out of 26 hospitals failed to treat emergency department patients on time, according to a Government report published last year.

Burnout among frontline staff and workforce shortages are also widespread in other parts of the NHS as healthcare workers deal with greater demands and treating patients with more complex needs.

But the scale of the crisis in the North and the trickle-down effect on basic patient care is different. Earlier this month a Belfast hospital ward ran out of bedsheets.

“Our emergency departments are congested because there’s simply not enough functioning hospital beds for patients to get into and that causes backlog through the system, causes delays in ambulance offloads and then causes risk in the community as well,” said McLaughlin.

Some Northern hospital consultants have quit their jobs to work in the South – a move unheard of 30 years ago.

McLaughlin, who lives in Co Down, was educated at Kill o’ the Grange national school in Cabinteely in south Co Dublin for several years when his father worked for RTÉ before moving back North.

He uses personal experience to explain why doctors in the North are moving South.

“I say to colleagues: do you remember when you were wee, and your mum and dad went down South and they complained about the roads? It was like, ‘we never buy the drink over the Border and we won’t take the car down there because it will wreck the suspension.’ And then, you flip that on its head now. Look at the roads in the South; the health analogy is the same. We were the NHS, it was brilliant and they didn’t know what they were doing down there,” he said.

“The consultant contract is also different in the South now and there’s definitely a draw. It would have been quite rare for people to go across the border. So you can definitely see this place on the slide.”

Asked to respond to concerns about excess deaths in the North’s emergency departments that are disproportionately higher than England’s, Stormont’s Department of Health said that it was “acutely aware” of the pressures and pointed to “similar challenges” faced in other jurisdictions.

Amid mounting pressure on doctors in the struggling health system, McLaughlin says ‘the frustrations, the powerlessness’ spur some on to stay in their jobs and ‘to make things better’

“The situation is reflective of the current pressures across the entire health and social care system, with demand for care outweighing existing capacity,” a department spokesman said.

He said the department “fully acknowledges that care will be far from optimal – and potential risks intensified – if hospitals are operating far beyond capacity, with the transfer of patients from ambulances delayed, and ambulance response times in the community consequently impacted”.

Amid mounting pressure on doctors in the struggling health system, McLaughlin says “the frustrations, the powerlessness” spur some on to stay in their jobs and “to make things better”.

“There’s probably some people who will dig in and [there is] – to use an Ulster word – ‘thranness’ to push forward,” he said, using a word best translated as stubbornness.

“Fundamentally, there is possibly a small kernel of optimism that, with the right circumstances, some of this is fixable. And ultimately, being a consultant in emergency medicine still retains some very rewarding elements in terms of the ability to treat very unwell patients and make them better quite quickly.”

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