Whole system flow - NICON webinar report

Background

Winter pressures on our HSC system in Northern Ireland have intensified over time, increasingly becoming a persistent, year-round challenge. As planning commenced for winter 2025, Health Minister Mike Nesbitt set in motion ‘The Big Discussion’, a whole systems conversation to learn from the previous winter. 

NICON organised a webinar on 16 January 2026 to take a closer look at the whole systems approach used in the Big Discussion. We heard inputs from key system leaders including Professor Maria McIlgorm, Chief Nursing Officer, DoH; Professor Cathy Harrison, Chief Pharmaceutical Officer, DoH; Maxine Paterson, Chief Executive, NIAS; Katy Rennick, Deputy Chief Nursing Officer, DoH; and Suzanne Pullins, Chief Executive, NHSCT.

Against the backdrop of a challenging flu season, we discussed the background, methodology, and outcomes of the Big Discussion as we prepared together for the remainder of the winter months.

The Big Discussion – Whole systems approach 

Context:

• The Big Discussion was an activity that ran in parallel to developing the winter preparedness plan, which brought together teams from across the Health and Social Care (HSC) system to analyse data and explore the drivers of demand.
• It sought long-term solutions to the increasing demand (not just one for winter) and focused on ‘red line’ issues, such as the normalisation of emergency departments (EDs) as the first point of contact for urgent care; long waits in and for ambulances; the normalisation of corridor care; and discharge delays.
• One goal of the Big Discussion was to understand the drivers of demand that put pressure on the system year-round, but peak in winter, to get to the root cause of these issues before considering solutions.
• Big Discussion participants considered potential solutions to improve pathways, to optimise flow, to utilise our resources in the most efficient way, and to more effectively meet the needs of the population.

Methodology:

• The Big Discussion was comprised of a series of workshops that took place in quick succession and were open to key stakeholders from across the HSC system. Participants included frontline clinical teams from HSC Trusts, primary care staff, the Royal Colleges, and representatives of the community and voluntary sector.
• A ‘Three Horizons’ change management approach was employed.
• As part of this process, the Patient Client Council (PCC) conducted a survey of patient views and experiences, which was published as ‘‘What the Public Think’ - Key findings from a PCC Attitudinal Report on People’s Experiences of Health and Social Care and ‘winter’ pressures’.

Key areas considered during the Big Discussion:

• The Big Discussion shifted the conversation to focus on how we can work differently to reduce avoidable harm, risk, and pressure in the first instance.
• Frailty was identified as a core issue, especially given that Northern Ireland is projected to have the largest increase in older people across the UK over the next 25 years. A decision was made early in this process to focus the Big Discussion and whole systems flow series intentionally through the lens of the older person.
• This made issues relating to medicines an important focus. It also prompted participants to ask how might we keep people well at home? How can we bring care closer to home and keep people out of hospitals?
• The results of the PCC survey showed a disconnect between services available to the public and their knowledge of them. It is important that we communicate through appropriate mediums and accessible platforms about alternative pathways for urgent and emergency care, as well as how and when patients can access them.
• People also need to know care delivered at or close to home is safe and can indeed be preferable to treatment elsewhere.
• The whole central theme throughout the Big Discussion was about getting people to the right service first time and preventing variation in access to services and waiting times.
• Consideration was also given to the need for better alignment of intervention and prevention strategies, while also considering the needs and wishes of the individual, and how these can be supported both now and at the end of life.
• Out of that whole systems approach, came seven clear Big Discussion projects:
  1. Keeping people well at home – enhanced care in care homes;
  2. Avoiding admission for end of life care;
  3. Provision of ‘sensible’ care (meaning reducing unwanted clinical variation and ensuring patients’ views are taken into account);
  4. Frail elderly pathway for ED attendees post-fall;
  5. Advance care planning;
  6. Fractured neck of femur pathway improvement group;
  7. Identification and risk stratification of frailty in over 65s.
• While seven projects cannot resolve all the challenges the system faces, these initiatives have brought teams together from across the system around the same issues to understand the demand and to work differently to begin to address these challenges.

Outcomes:

• Participants in the Big Discussion felt that it was a different experience from previous discussions because there was an intentional move away from focusing on individual parts of the system towards understanding demand, risk, and flow together as one system. This approach was very beneficial:
  • It helped dispel the myths and shifted the conversation from conveyance as a first option to making better decisions ‘upstream’;
  • It enabled more honest conversations about constraints, a clearer understanding of the interdependencies, and a greater confidence in learning together;
  • It also demonstrated the importance of coming to agreements as a system and taking ‘stewardship’ of that decision-making.
• The Big Discussion joined up data from across the system in a way it had not been previously, allowing for patterns to be more easily distinguished.
• NICON members praised whole systems aspect of the Big Discussion, particularly because it offered an opportunity for participants to get into the room and think energetically around the challenges and the solutions that could be brought forward. It allowed them to look at pathways across the five trusts, collectively.
• While whole systems working takes more effort up front, it was felt that this approach ultimately leads to better decisions.
• One key takeaway from the Big Discussion was that consistency is key as this helps ensure there is less variation in pathways and in treatment.
• Following the Big Discussion, there has been improvements in how demand is managed. Participants credited this to the new connections and relationships that have been formed. There has been a cultural and relational shift - a recognition that the whole system needs to move at the same time.
• Some NICON members said that the Big Discussion made them reflect on their own internal practices and the need to optimise every element of the service for the whole system to work as best it can.
• The Big Discussion was also viewed as helping ‘accelerate’ thinking around the new neighbourhood model within health and social care, which will see the in establishment of integrated neighbourhood teams.
• Ultimately, participants viewed the Big Discussion not just as a solution for winter, but as a longer-term solution for how we reset the system in NI to manage our population differently and get better outcomes. This was seen as particularly important given the current challenging financial climate.

Learn more

You can watch the session on YouTube. If you have questions about the webinar or this briefing, please email contact@niconfedhss.org.

This webinar was held as part of NICON’s 'Reset' discussion series, which will run throughout 2026.