Image copyright PA

Increasing pressures on funding means "something has to give", Northern Ireland's health chief has warned.

Richard Pengelly, who in the absence of a health minister is effectively in charge, said services were moving into their "most challenging ever period".

He said change was never easy in health and they could no longer "duck decisions".

"If we did, then we will be heading over the cliff edge into a full-blown crisis," he said.

Speaking at a Healthcare Financial Management Association event, Mr Pengelly said patients and taxpayers deserved honesty, realism and transparency about the scale of the challenges facing the health service.

Image caption Richard Pengelly is Northern Ireland's permanent health secretary

"Something has to give in that situation," he said.

"We can see it in our growing waiting lists and the impact these have on public confidence in the system.

"And it's also very evident in the rising tide of frustration without our workforce."

Strike ballot

A Department of Health statement said Northern Ireland was in a defining period for health and social care as budgets remained under intense pressure, while at the same time demand continued to grow.

The comments come at a time when hospital waiting lists are soaring, and also on the day when the Royal College of Nursing (RCN) began balloting members on potential strike action.

In June, Mr Pengelly said it would take £1bn to tackle NI's waiting list crisis.

The department however has warned it has to live within its budget and it does not have the money to do everything it was being asked to do.

Unions however would argue there are major problems around pay recruitment and retention of highly-skilled staff.

It is not the first time alarm bells have been sounded but then it is coming up on three years since the executive has been in place to make tough decisions..