Comment / Bermuda shorts 11: a winter’s tale

The US has been battered by a polar vortex, with the population in Chicago warned of the dangers of speaking when outdoors. And the UK has had its own cold snap, with headlines speculating about the latest ‘beast from the East'.  Meanwhile, I found out that the last time it snowed in Bermuda was 1942.

We did, however, have a hailstorm recently, which is, apparently, not that uncommon. And, in healthcare terms, we are becoming all too familiar with similar winter pressures to the NHS.

Albeit on a much smaller scale, we have seen a significant number of confirmed H1N1 flu cases in our intensive care unit and the numbers of patients attending the emergency department with flu-like symptoms and similar seasonal complaints increases each year. Encouraging our staff to get the vaccine is still something of a challenge and urban myths about the potential ill-effects of the flu jab, as opposed to the very real, sometimes fatal consequences of the virus itself, proliferate.

Against this backdrop, I attended the Caribbean Infrastructure Forum in Nassau, Bahamas, in early December which was very interesting from a health system perspective as it relates to Bermuda and the Caribbean. Of all the countries in the region, only six have a population of more than 500,000, 14 have populations between 50,000 and 500,000 and eight have populations lower than 50,000. This presents problems for healthcare planning from two perspectives:

• Given the proliferation of insurance-based systems, many countries have populations that are too small to have effective risk pools. For example, the population of Bermuda is 63,000 and, of this, 49,000 have health insurance coverage. Therefore, even with the proposed move to a unitary or dual fund that I mentioned last time, which would reduce the existing pools from over five to one or two, this still represents a very small pool;
• Second, specialist care requires populations of at least 500,000. The hub and spoke models that work well in larger jurisdictions inevitably run into difficulty when it comes to determining who will be the spoke, rather than hub. Independent countries are unwilling, for the most part, to agree to another jurisdiction performing the more specialist care.

KPMG, which authored a report on the subject, speculates that, given the relative cost differentials between insurance-based models and the alternatives, this may lead countries to look at universal health coverage, something that with the notable exception of Cuba, has been largely shunned in the region.

Back in Bermuda, discussions with the Ministry of Health on our financial settlement for 2019/20 have been ongoing for some time. It is clear that the inexorable rises in spend, caused by the twin dynamics of insurance coverage on the one hand and utilisation increases driven by a fee for service model on the other, are no longer desirable or sustainable.

We have yet to conclude our discussions, which are subject to cabinet approval and will be heavily influenced by the Ministry of Finance’s budget later this month. But it is clear that a cap on revenue increases will be a feature of any agreement. This will require a focus on cost containment as opposed to relying, predominantly, on utilisation to resolve funding gaps, again echoing the need for alternative models to be found.

It seems to me that the NHS faces a very different challenge, namely the ability to adhere to funding promises in the wake of an unknown future after Brexit in a system funded from general taxation and free at the point of delivery. The ability of the government to continue to act as insurer for the entire population and widespread resistance to any form of co-pay being levied will surely be tested in tougher economic climes going forward.

Technology must be an enabler to the levels of system change required in healthcare and earlier this month, I visited Johns Hopkins again to look at a potential solution for our electronic medical record needs. We continue to utilise a number of legacy systems and paper, in some cases, to record activity, patient details and billing information.

Johns Hopkins recently completed the installation of Epic across its entire system in Baltimore, Washington DC and Florida. Again, its commitment to getting things right first time and resourcing change management effectively speaks to the culture of the organisation.

As we look to finalise our decision and produce an outline business case, I am visiting the Healthcare Information and Management Systems Society 2019 convention in Florida during February to meet with vendors, hopefully see some sunshine and chase down those elusive bananas.

Bill Shields was chief financial officer at Bermuda Hospitals Board from April 2017 to November 2022. He is now chief finance officer at Devon Integrated Care Board.

All the blogs from this series can be accessed here