Four health campaign groups have joined to write a letter to The Executive Office (TEO)
On 19th October 2026, a Joint Letter of Concern was signed by representatives of Rural Acute Hospital Services in Northern Ireland for the attention of all the Ministers in the Northern Ireland Executive.
The four signatories were from the Save Our Acute Services (SOAS) – SWAH; Causeway Hospital SOS Campaign; Save Our Services – Daisy Hill; and the Down Community Health Committee – Downe Hospital.
The letter stated:
To All Ministers in the Northern Ireland Executive.
Dear Ministers,
We write jointly on behalf of our campaign groups, representing rural communities who face the real threat of being cut off from timely access to acute and other vital hospital services.
Our communities have seen the same pattern again and again: decisions framed as purely operational or clinical, with too little cross-departmental scrutiny and no meaningful consultation.
The devastating consequences fall on our local communities who need vital, basic healthcare. Rural proofing is non-existent Under the Rural Needs Act (NI) 2016, public authorities are under a statutory duty to have ‘due regard to rural needs’ when developing, adopting, implementing or revising policies and services. This is not discretionary. The act was designed to ensure ‘equitable’ not merely ‘equal’ treatment of people in rural areas.
Yet the lived reality in our communities tells a different story. Decisions have been repeatedly made without meaningful assessment of the differential impact on our communities.
These service changes – whether planned or as a result of collapse – compromise our basic human rights including our right to life. These changes affect rural dwellers in particular.
The removal of timely access to acute health services compounds the disadvantages already faced by rural communities.
In the foreword to Thinking Rural: The Essential Guide to Rural Proofing (2015), Michelle O’Neill MLA – then Minister of Agriculture and Rural Development – warned that:
“Continued withdrawal of services, or lack of consideration for rural differences, can compound social isolation and create a ‘domino effect’ that depletes rural areas of community spirit, strong
cohesion and good quality of life.” Yet this warning appears to have been disregarded in the ongoing erosion of rural acute-care provision.
As a result, our communities are forced to travel long, unsafe distances for emergency care when they are at their most vulnerable. These service removals have deepened the disadvantages our communities already face and put our health and lives at greater risk.
With ambulance staffing and waiting times under pressure, patients are too often transferred in non-emergency ambulances without a paramedic. Separately, some patients are asked to find a friend or relative to drive them in a private car. Both can mean a long journey on poor rural roads without the medical equipment, training or support needed if the patient’s condition deteriorates.
Equality is being treated as a box-ticking exercise.
Section 75 of the Northern Ireland act 1998 requires public authorities to have due regard to the need to promote equality of opportunity across nine protected categories. The Equality Commission’s guidance makes clear that equality considerations should be part of everyday policy-making, rather than added later to defend decisions already taken.
The last census showed that 43% of households contain at least one person with a long-term health problem or disability. Rural communities are disproportionately composed of Section 75 groups. The equality impact is further exacerbated by longstanding underinvestment in infrastructure and public transport.
When services are removed from rural hospitals, the equality impact falls heaviest on older people, people with disabilities and those without access to private transport. A system that requires tens of thousands of patients to travel hours simply to reach emergency services at their nearest hospital is not delivering equality; it is entrenching inequality.
Recently, with concern, we have seen the Department of Health Permanent Secretary suggest a generalised move away from conducting public consultations around controversial service changes altogether. This makes a mockery of the equality provisions in the Good Friday/Belfast Agreement (1998).
Health rights are denied on the basis of geography.
All individuals, regardless of where they live, have the same statutory right to request an assessment of their health and care needs. Yet the practical realisation of that right depends entirely on geography. We simply ask for the same likelihood to live and to die as anywhere else.
Currently that is being denied us.
Removing maternity services and emergency general surgery—which is vital to providing safe, sustainable maternity care – disproportionately affects women in rural areas. It forces them to travel long distances to give birth in unfamiliar hospitals, away from family support. This undermines their safety, dignity and basic rights to women’s healthcare. Controversial cross-departmental decisions need full Executive agreement.
The removal or non-restoration of acute or other vital hospital services in rural areas is not and cannot be a purely operational matter for the Department of Health or individual health trusts. Under the Northern Ireland Act (1998) and the Ministerial Code, matters that cut across the responsibilities of two or more Ministers or that are significant and controversial – must be brought to the Executive Committee for discussion and agreement.
Hospital service reconfiguration in rural areas – which is clearly significant and controversial – necessarily and unavoidably impacts the responsibilities of multiple departments:
- Health – clearly directly involved in these service changes
- Infrastructure — because transport poverty and inequality directly determine whether patients can access services at all and compounds disadvantage
- Agriculture, Environment, and Rural Affairs — because the Rural Needs Act 2016 imposes a statutory duty of due regard that must be assessed before decisions are taken
- Communities — because rural isolation and social cohesion are directly affected by the withdrawal of local services
- Finance — because the costs of centralisation are often transferred rather than eliminated, with negative effects falling on patients, families and other public services
- Economy — because rural businesses need access to basic and acute hospital services to ensure operational and workplace safety.
Next Steps
Decisions to remove vital and acute hospital services from our local hospitals are undeniably significant and controversial. They must be decided collectively by the executive, not unilaterally by the Minister of Health or a local trust.
We therefore call on all Executive Ministers to take the following steps:
- Immediately refer all decisions relating to the removal, suspension, or non-restoration of acute hospital services in rural areas to the Executive committee for collective decisionmaking, in accordance with section 20(3) and (4) of the Northern Ireland Act 1998 and section 2.4 of the Ministerial Code.
- Commission a full, independent Rural Needs Impact Assessment for every proposed service change, conducted before any decision is made, published in full and subject to full and meaningful public consultation. This assessment must specifically address the cumulative and compound impact of service withdrawals on rural communities and not merely the impact of individual proposals in isolation.
- Conduct an independent and comprehensive Equality Impact Assessment that examines the differential impact of all relevant service changes on all Section 75 categories, with particular attention to the disadvantages faced by rural dwellers who are older, disabled or without access to private transport.
- Establish a cross-departmental ministerial working group on Rural Health Access, including representation from Health, Infrastructure, DAERA, Communities, Finance and Economy, with a remit to address the structural barriers – including transport, workforce and funding –
that are currently undermining equitable rural healthcare. - Commit to a presumption of restoration where services have been removed from rural hospitals without adequate evidence of rural proofing, equality assessment or executive scrutiny, and to publish a timetable or roadmap for restoration.
We have witnessed too many ‘temporary’ but open-ended suspensions, too many unexpected and unjustified withdrawal announcements and too many unfulfilled promises that rural proofing or consultations will be genuine and that our communities will be listened to.
The legal obligations protecting rural communities do exist.
The evidence of harm is manifest.
What is missing is the political will to act. We look forward to your urgent response.
Yours sincerely,
Save Our Acute Services (SOAS) – SWAH
email: [email protected]
Causeway Hospital SOS Campaign
email: [email protected]
Save Our Services – Daisy Hill
email: [email protected]
Down Community Health Committee
email: [email protected]
