Comment / Bermuda shorts 15: Shaken not stirred

I hope you all had an enjoyable summer break. The latter part of my UK homecoming tour was spent in Speyside, Islay and Campbeltown, or more specifically, Glen Allachie, Macallan, Bruichladdich, Ardbeg and Glen Scotia distilleries! I have always wanted to do a distillery tour and having a designated driver who’s not that keen on the ‘water of life’ was a real boon.

In Bermuda, summer’s end was marked by hurricane Humberto, which passed within 60 nautical miles as a category 3 storm. I understand it continued to the UK and was responsible for heavy rainfall in the West of England, but here we had very little rain or any perceptible storm surge.

What we did experience, however, was hurricane force winds with a high of 130mph and tornadic activity both being recorded.

In Bermuda Hospitals Board (BHB), when it becomes clear a tropical storm or hurricane is likely to pass very close, or directly over the island, the hospital goes into lockdown – meaning no members of staff can enter or leave the premises. Operational management also passes to the Hurricane Incident Control Centre (HICC). HICC is usually established for at least 12 hours and is in close contact with the Emergency Measures Organisation (EMO), where gold command resides. Unusually, compared with the UK, during Humberto the national security minister sat in EMO, enabling rapid decision making and responsiveness.

So, what was it like being in a hurricane having avoided it for the first two and a half years out here? In truth, pretty scary and quite surreal. The high winds are not accompanied by the cold of a winter storm but, rather, the same humidity levels we have seen throughout the summer.

Damage was quite widespread across the country with many power lines, telephone poles and trees blown over. There was extensive windburn of plants. Roofs, cars and boats were damaged or destroyed. As a consequence, large parts of the island were without power, in my own case, for four days.

This latter inconvenience would be less of an issue if Bermuda wasn’t reliant on electricity to pump domestic water from tanks below each house. The thought of no power, water, shower, food, WiFi or air conditioning was not too attractive to me and was marginally worse than sleeping in my office on an inflatable bed and eating out for every meal.

The other major feature of the past two months for me has been the amount of time I’ve spent in Baltimore. My wife Avril was scheduled for a routine outpatient (daycase in UK parlance) procedure, but the pre-operative consultation revealed a number of complications that meant surgery couldn’t take place.

Usually, this would be fairly routine – the patient goes home, the issue is resolved and surgery is rescheduled when their vitals are normal. When you’ve travelled by plane with a connection, however, healthcare providers need to issue a fitness to fly certificate. This took five weeks to be signed off due to the diagnostic tests and medication required.

I’ve experienced and witnessed the delivery of excellent care in the providers I’ve worked for in my career. But US academic medical centres, such as Johns Hopkins, take this to a different level. The ability to marry high-quality care, immediate access to diagnostics, provision of test results through email or an app on your phone and excellent customer service is something I have not seen done in such an effective way anywhere else.

 I’m sure many of my cynical, hard-bitten, ex-NHS colleagues will be thinking that’s only possible in fee-for-service, insurance-based healthcare where a country spends 18% of GDP and rising on healthcare. But what price is great patient experience?

Finally, work has commenced between BHB and the Bermuda Health Council to research and recommend the future funding model for the hospital. As you may recall, we moved from a US-style fee for service model to a block budget in June of this year, but this was always seen as a temporary measure pending a long-term solution to incentivise value rather than utilisation.

We are, therefore, like many jurisdictions, trying to solve the conundrum of how to deliver high quality care while minimising costs and do this in a sustainable way. No health system has managed to crack this completely. The NHS has a better track record on cost optimisation than any other system. But as funding pressures have increased over the last 10 years, access, performance and the condition of infrastructure have suffered.

The US system, perhaps because it is insurance-based and so subject to increased patient pressure, places access above every other indicator. Some states, including Maryland have, however, taken concerted steps to cap the seemingly inexorable rise in healthcare expenditure and we will, no doubt, look at this experience among others.

Talking of which, I was tickled when my colleague from the health council included a seminal document from the UK in his literature search – Global Health Budgeting written in 2004 by fellow former HFMA chairman Bob Dredge! It really is a small world.

I will keep you apprised of developments and hope to see many of you in person at the HFMA annual conference in London.

Until the next time, good day!

Bill will be presenting 'A case study from Bermuda Hospitals Board' in a workshop at this year's HFMA annual conference. He will be exploring both the opportunities and challenges and question what the UK can learn from this international healthcare system. Book now. 

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