Northern Ireland’s minister of health talks about why underfunding his comprehensive mental health strategy is cruel.
Mike Nesbitt has made the healthcare portfolio his own with a hands-on approach and, crucially, an understanding that is rare. Minister of health in Northern Ireland since May 2024, the former broadcaster has also headed up the Ulster Unionist Party since August Last year.
He speaks to Healthcare Today about how his interest in mental health was shaped by his position as a commissioner of Victims and Survivors, a Northern Ireland Assembly role designed to promote the interests of victims of the Troubles, how he plans to address the healthcare problems caused by underfunding, and why he has opened a public consultation on the redesign of the current Serious Adverse Incident (SAI) procedure.
“The fundamental issue we face is that the health service now consumes just over 50% of the Northern Ireland Executive’s budget.”
Northern Ireland has the depressingly familiar problem of long waiting times for surgeries and specialist appointments. How are you addressing that?
The fundamental issue we face is that the health service now consumes just over 50% of the Northern Ireland Executive’s budget. Yet, when assessed against objective need, we actually need slightly more – a case that has proven exceedingly difficult to argue within a four-party mandatory coalition.
To provide some context, previously, the Barnett consequentials had been calculated using a crude headcount formula, whereas we argued – and secured – funding based on assessed need. As a result, Northern Ireland now receives £1.2124 for every £1 spent on public services in England.
But when I attempted to apply the same principle of objective need to the health budget within that block grant, the request was rejected. Consequently, we have been unable to implement the reforms that everyone claims to support and the situation has deteriorated year after year.
The legacy of underinvestment has left us with severe challenges, particularly in hospital waiting lists. My priority, however, is to move the focus from treating illness to preventing it, strengthening primary and community care and properly resourcing social care. One of the key reasons our acute hospitals struggle, especially during winter, is the lack of care beds and domiciliary care packages. This creates bottlenecks at the back door of hospitals, even though public attention tends to fixate on A&E pressures at the front door.
How do you square that circle? How can you integrate health and social care services?
I often refer to additional winter pressures rather than just winter pressures, because these strains are now a year-round issue. During the crisis period just after Christmas, I promised that by late February or early March, I would bring together all stakeholders – everyone with a role or an opinion – to start afresh with a blank sheet of paper. And we did exactly that.
The first of four planned workshops took place on 4 March, with around 130 attendees in the room. In fact, demand was so high that we even had a waiting list. The approach was deliberate: rather than rushing to propose solutions, we began by collectively acknowledging the problems. What are the issues? Do we agree on them? The answer was yes – there was broad consensus because, at its core, this is about flow.
The challenges may manifest in emergency departments, but the root causes lie elsewhere. As some emergency medicine consultants rightly argue, doubling the size of A&Es won’t solve the problem. Instead, we need a whole-system approach: tracing the patient journey from the moment an ambulance is called, through admission and beyond.
A critical bottleneck arises when patients are deemed medically fit for discharge but cannot leave hospital due to insufficient social care capacity.
Admittedly, the blank page exercise is partly symbolic – many solutions are already evident. For instance, I’ve moved to introduce the Real Living Wage for social care workers, making the sector more attractive to recruit and retain staff. With three more workshops scheduled, culminating in June, the goal is to produce an agreed plan. It may not resolve every issue, but it will sharpen our understanding of the problems and ensure available resources are directed where they can achieve the greatest impact.
“It isn’t solely about money – and if it were, we’d be in grave difficulty.”
What are you doing to tackle staff shortages and retention, particularly in nursing and general practice? Wages are obviously part of it, but not all of it.
It isn’t solely about money – and if it were, we’d be in grave difficulty. Social care providers in the Republic of Ireland can offer salaries we simply cannot match, which hits us hardest in border regions. Commuting from Belfast to Dublin now takes under two hours, making cross-border employment a viable option for many.
Our response must therefore focus on creating a working environment that attracts and retains staff – one where people feel valued and see genuine career progression. I’ve challenged our leadership team, including the chief medical officer and chief nursing officer, to explore how we can better structure roles to make them more appealing. Recruitment is only part of the battle; retention is equally critical.
How are you tackling healthcare access for both the urban underserved and the rural unserved parts of the population?
My new initiative, Live Better, will initially focus on an urban setting. This approach allows us to gather robust empirical evidence more effectively within a concentrated geographic area with higher population density, rather than starting in a rural context.
The international research we’ve reviewed indicates that health inequalities are only 20% attributable to healthcare interventions. The remaining factors break down as 40% socioeconomic, 10% environmental, and 30% behavioural. I’ve been transparent with executive colleagues about my approach: I’m starting with the 20% within my remit, but if we demonstrate progress, I’ll be calling on the economy minister and others to address the socioeconomic dimensions. The initial response has been encouraging.
We’ve selected two tightly defined urban areas for the pilot: one in Belfast and another in Derry/Londonderry. The first day in Derry far exceeded expectations – we anticipated around 50 participants for mobile health checks, but 130 attended. This demonstrates that bringing services closer to people’s homes significantly increases engagement.
Our key metric isn’t simply life expectancy, but healthy life expectancy. The disparities here are stark. Research shows that on a bus journey from Belfast city centre to the affluent suburbs, healthy life expectancy improves with every few minutes travelled. Most shockingly, two babies born on the same day in the same Belfast hospital, but raised in the most and least deprived areas respectively, face a 14.2-year gap in healthy life expectancy.
As we’re now a quarter of the way through the 21st Century in a developed nation, such inequality is intolerable. Success here would not only restore public confidence in devolved government but also demonstrate our capacity to tackle Northern Ireland’s most entrenched inequalities.
“Thirty years ago, my wife Linda experienced clinical depression. Being her partner through that journey taught me valuable lessons.”
We covered the opening of a public consultation on the redesign of the current Serious Adverse Incident (SAI) procedure in Northern Ireland recently. Why is the review needed? What are you hoping for?
The Serious Adverse Incident (SAI) framework required review because, frankly, it isn’t fit for purpose. One of the most pressing concerns has been the sluggish pace of investigations. We need timely outcomes to implement meaningful changes.
This review takes on added significance when we consider recent healthcare scandals, both within the UK and internationally.
Currently, there’s vigorous debate in Stormont about the scope of this duty. While an organisational duty of candour is an absolute necessity, in my view, the question of individual liability with criminal sanctions remains contentious.
I have serious reservations about the potential chilling effect. This isn’t simply about staff retention; it could fundamentally impact our ability to recruit healthcare professionals. If Northern Ireland establishes the most punitive regime compared to England, Scotland, Wales and the Republic, will talented clinicians choose to work elsewhere? The SAI review must be considered within this wider context of how we respond when things go wrong while maintaining a system that attracts and retains the skilled workforce our health service needs.
Mental health services in Northern Ireland are underfunded compared to other UK regions. What is your plan to improve access and funding for these services?
This issue is deeply personal to me for two reasons. Thirty years ago, my wife Linda experienced clinical depression. Being her partner through that journey taught me valuable lessons – particularly how we tend to over-medicalise mental health, relying too heavily on pharmaceutical interventions as both first and last resort.
My second perspective comes from my pre-political role as commissioner for Victims and Survivors of the Troubles. In 2025, the conflict’s most toxic legacy remains poor mental health. The geographical correlation is striking: overlay a map of Troubles hotspots (marked by shootings, bombings and murders) with current mental health indicators (suicide attempts, substance abuse), and the patterns match exactly. This makes mental health uniquely a public health crisis in Northern Ireland and we have a comprehensive mental health strategy.
Yet herein lies the tragedy: while the strategy outlines what could be achieved with £64 million funding, we’re currently spending just £5.9 million.
It feels almost cruel to present such a vision without the means to realise it.
You were in the US, in Washington recently. What can Northern Ireland learn from US healthcare?
I took away two or three things. First, we’ve established a promising connection with a substance abuse organisation. Their enthusiasm during our introductory meeting was palpable – they’re examining the intersection of mental health, suicide and substance use, and have developed several innovative approaches that we plan to adapt to our context.
During visits to two emergency departments, including a sprawling new £800 million facility with a state-of-the-art emergency department, I observed a sobering reality: patients on trolleys lining every corridor. When I asked if this was typical, staff confirmed it’s a year-round occurrence – so much so that they’ve established dedicated corridor care teams. The scale at MedStar Georgetown University Hospital particularly surprised me; we often assume our winter corridor pressures are unique, but this appears to be a widespread challenge.
Similarly, when inquiring about ambulance handovers, I learned they experience the same queues that plague our Northern Irish system. The overarching lesson? Our struggles aren’t exceptional – they’re part of a broader pattern affecting healthcare systems internationally.
