Health and social service providers in Northern Ireland are bracing themselves for a radical shake-up in their structure that could see the 18 trusts and four health and social services boards reduced to just four main players.

The Hayes review, published on June 20, insists change is needed because Northern Ireland has the longest per capita hospital waiting lists in the UK.

Waiting times are no better, with the number of patients waiting 18 months or more for treatment rising from 632 in March 1996 to 5,200 in March 2000. Trusts' financial positions are poor - in 1998/99 they had a combined deficit of £6.8m and in 1999/2000 this rose to £15.6m.

Spending on hospital and community care is due to rise to £1.27bn by 2003/04, but the committee points out that a further £141m is needed to match spending in the north-east of England. It also calls for more efficient use of beds - if trusts in the province could match their counterparts in England the waiting list would be wiped out in just over a year, it says.

Greater resources and efficiency should be enhanced with structural change. It recommends the four health boards be scrapped in favour of a central commissioning authority. The trusts would be replaced by three health and social care systems.

They would be:
• The northern health and social care system, covering hospitals from Derry to Antrim
• The southern health and social care system, stretching from Enniskillen to Craigavon
• The Greater Belfast health and social care system.

There are presently 15 acute hospitals in Northern Ireland and the review recommends there should be nine main hospitals - the so-called golden six (Antrim, Belfast City, the Royal Group, Ulster, Craigavon and Altnagelvin) and a new hospital in Enniskillen plus hospitals in Newry and Coleraine. This configuration should ensure the entire population has access to hospital services within an hour.

Reaction has been mixed. Alan Gilbert, spokesman for the Northern Ireland Confederation of Health and Social Services which is part of the NHS Confederation, welcomed the report.

"Since December we have been developing a campaign on the need for greater resources in our health service and the committee has built on that. The report also recognises the decline in morale in the service at all levels and the need to take action on this," he said.

Health and social care is integrated in Northern Ireland and though the recommendations would impact on social care - it would be an integral part of the new health systems - social services directors feel the report barely addresses their area.

One of the few passages concerning social care reads: "The integration of health and social care services in Northern Ireland was seen by the vast majority of people we spoke to as a strength. However, the need for further on-the-ground operational integration was recognised as a key requirement for the delivery of a truly seamless service."

This may mean greater use of multi-disciplinary teams but Noel Rooney, secretary of the Association of Directors of Social Services in Northern Ireland, says this is confusing since the system is already integrated.

"The implications for social care are not clear and they need to be teased out during the discussion period. The document presents as though we do not have an integrated model here."

Mr Rooney acknowledges social care was not included in the review's terms of reference but points out that primary care was also missing from the brief yet the report discusses it in some detail.

"Overall, the recommendations appear to make sense in the way they affect acute hospitals but we would have wanted to see some discussion of the implications for integrated health and social services," he added.

Other recommendations will prove controversial. The report proposes downgrading services at six hospitals, including the casualty unit at the Tyrone County hospital, which treated many of those injured in the Omagh bombing in 1998. The proposed new hospital in Enniskillen would further endanger services at the county.

Local opposition will be led by Omagh district council, which held an emergency meeting two days after the report was published. A spokesman for the council said a further meeting on June 29 would agree a plan of action.

In Northern Ireland, the conflict between the communities is never far away. The committee's recommendation that the Royal Group of Hospitals trust in nationalist west Belfast be part of a merger with the Belfast City hospital in a neighbouring unionist area and the Green Park trust will be hotly disputed, especially with the inevitable run-down of services at the hospitals.

The future of the Northern Ireland assembly will also be crucial. With first minister David Trimble threatening to resign on July 1 if the IRA does not begin decommissioning arms, the local power-sharing executive could be in mothballs by mid-August.

Mr Gilbert says action is needed, whatever the position of the assembly. "We must not be put in the position where no progress can be made because then we could be looking at the collapse of some services."