CEO and Chairman Speak at Hamilton Rotary

Jonathan Brewin, Chairman, Bermuda Hospitals Board:

First and foremost, thank you for having me here today. With me is the Chief Executive Officer of Bermuda Hospitals Board, Mrs Venetta Symonds. We are both here to speak today as the demands, challenges and opportunities we face require an unprecedented level of cooperation, transparency and understanding between the Board and leadership of BHB.
When I was appointed Chairman in February of this year, I asked Mrs Symonds to give me and the new Board as much information as possible so that we could orient ourselves quickly. I had been Chairman of the Board almost ten years before, from 2003 to 2005, and this, along with my experience in hospital management in the UK, meant I knew it is normal for healthcare to change fast and furiously. For BHB, however, not only had technology, treatments and services changed, but the new acute care wing was already well underway, a new mental health plan was being rolled out and like all of Bermuda BHB was operating in one of the most difficult economic periods in living memory.
We knew the financial position of the hospital was going to be pressured due to the economic issues in Bermuda. But the scale of the problem should concern us all. If nothing is done, BHB will run out of money by the end of Spring 2014. If we do not act, over the next five years BHB losses could run in excess of $200 million. Why such a major problem? In an attempt to control spiraling healthcare costs, BHB had agreed to set revenue caps with insurers. This certainly brought some stability to the system for insurers, but as the use of services continued to rise, and healthcare costs continued to rise in line with the rest of the world, BHB was essentially undertaking additional work it was not getting paid for.
BHB’s cost base had also increased due to a strategy driven by public demand to increase services on island and additional revenue for the hospital . This meant that BHB hired additional specialists. Cancer care in Bermuda stabilized under three oncologists, employed cardiologists were raising the quality of care for people with heart disease and new tests were available, including a new CT scan that could undertake cardio angiograms and virtual colonoscopies, and a cutting edge screening technology that vastly improves the early detection of cervical cancer. But the costs to support these new services and specialists had also risen dramatically. For example, there are about 350 additional staff members compared to seven years ago.
There was also the new acute care wing on the way, heralding a new era in acute care in Bermuda, but also financial obligations that start in 2014. According to the terms of the public private partnership, there will be a $40 million one-off payment to be made at substantial completion, and payments that will total $26.7 million in the first year and continue for 30 years. While maintenance of the new wing is covered in the payments to Paget Health Services, there are operating costs to consider, such as utilities, which will increase costs. In addition, BHB was notified this month that there would be a charge for work permits. This is the first time for BHB, and we estimate it will cost BHB about $650,000 annually.
More money will be going out and, as the Board discovered in the month it was appointed, even less money was going to be coming in. The Ministry of Health & Seniors informed us in February that it would no longer pay the fees of residents of the Continuing Care Unit. Previously, the majority of residents received support from the geriatric subsidy. The Ministry was not legally obliged to pay this and so decided to stop. It costs over $14 million to run the unit, and we expect CCU to keep operating for several years. That money will now come from the revenue we earn from acute care services, revenue which is already capped, and money which would have gone towards the acute care wing payments and investment in existing facilities and services.
The previous Board realized that BHB would be seriously challenged financially. A review of physician compensation was initiated as it had become clear there was great inequity in the contracts. Reviews were undertaken to look at BHB’s ability to meet the financial obligations of the new acute care wing, and also the impact of the revenue caps. Summaries of all these reports have now been made public. A Clinical and Corporate Governance Review was underway and the Bermuda Ombudsman had agreed to review the review. Both these reports have been made fully public. But as we sought a way forward, for example implementing the recommendations of the physician compensation report, and strengthening Board governance and structures, the Auditor General recommended that the Department of Internal Audit undertake a review of the finances of BHB for the fiscal year 2011-12.
It might well have seemed to be a time of crisis. But the benefit of all these reports and reviews meant we actually had a wealth of information to support a new way forward. We also had a Board, senior management team, physicians and staff at BHB who were absolutely committed to do whatever was needed to ensure we were clearly focused on quality patient care for the community.
We certainly are standing at a moment in history. Change is necessary and unavoidable, and our challenge is to ensure we work with community and overseas providers, the Ministry, insurers and the people who use and pay for our services to make healthcare more affordable and effective. We have a tough challenge, but it is widely recognized that the rising cost of health care is unsustainable and liable to damage our country, our businesses and residents if we do not address it. This brings many more people to the table, looking for solutions and seeking to cooperate and co-exist, rather than compete, in order to ensure people in Bermuda can continue to access the right services at the right time at a price they can afford.
Good intentions are not enough without purpose and direction. At BHB we are working strategically and seeking input from community members to assist in developing a financial sustainability plan. A Financial Sustainability Steering Committee, comprising board members, community members and hospital leadership is already meeting, and subcommittees focusing on strategic, operational and structural sustainability are being established. We are working hard to establish a new dialog with all our partners in healthcare—community physicians, overseas affiliates, patients, insurers, the Ministry of Health and Seniors and the Bermuda Health Council—to ensure collaboration as we proceed to address urgently needed change in the overall healthcare system.
Our aspiration is to build a safe, high quality healthcare system that always puts the patient, those who are less fortunate than ourselves, at its heart.
John F Kennedy said: “Do not pray for easy lives, pray to be stronger men”. We face a difficult journey ahead in healthcare. Change is no longer a long term option. It is required now . And while the road ahead looks hard, steep and painful, we must move on to ensure quality and contain costs. There are solutions out there that make the journey worthwhile. To accept the status quo and not move on means that healthcare will become unaffordable, and people and Government will become mired in even more debt. Private insurers will be forced out of the market, or have to raise premiums to a point that individuals and businesses can no longer afford them. If we want new hotels, new tourism services and new international business partners to regard Bermuda as a good place to conduct business, we need to address healthcare. Accepting the status quo is like sitting down in a leaky boat and not realizing that we don’t have long before we go under. We will sink if we do not swim.

Venetta Symonds, Chief Executive Officer, Bermuda Hospitals Board
This sounds like a grim picture. And in many ways it is. But it is also not unheard of in the development of hospital services around the world. Many hospitals are struggling in the US, Canada and Europe in exactly the same way as we are in Bermuda. Indeed, as a single healthcare provider on an isolated island BHB has, in many ways, been shaped by crises in Bermuda – whether disease, war, economic hardship, or clinical capacity.
I understand that our very first hospitals on the island were built in response to epidemics of malaria, smallpox and yellow fever. Our first six-bed cottage hospital was built in 1894 and founded purely on donations. Within eight years it had been forced to expand three times – first adding six new rooms, then isolation wards and finally, in 1902, an operating room. In 1913 – one hundred years this year – the General Hospital Act was passed, identifying the need for a bigger general hospital to be built on Point Finger Road. Since then, the major constructions that have taken place and the demand for more services and higher utilization of services, have consistently increased costs at BHB. We have also seen a number of other healthcare providers set up in the private sector and expanded overseas relationships, which are currently unregulated. The result, today, is an unprecedented level of access to on-island and overseas healthcare. If we want a CT or MRI, we can get it in 24 hours. Chemotherapy? Cardiac specialist consultations? Vascular surgery – you’ve got it all on your doorstep. But we pay for it in spiraling premiums that we can no longer afford.
Certainly these increases have led to clinical improvements over the last ten years that impact both patient outcomes and reduce costs. Diabetes rates could be as high as 25% in Bermuda so we hired an endocrinologist who is working hard to support and establish services that, for example, could reduce the potential numbers of amputees. Hospitalists were introduced – and this was an added cost to inpatient care – but mortality in six of the main disease categories has dropped from 21% to 6% and length of stay has reduced which lowers costs. $2.8 million was saved in hospital bills if you compare length of stay in 2012 to 2004.
But something has to give. Can BHB control the use of services, something referred to in healthcare as utilization? The answer is yes. Tests are carried out that are not always supported by clinical best practices. Clinical evidence suggest that an individual suffering from low back pain does not need an MRI unless the pain lasts longer than six weeks or there are potential “warning signs” such as fever, cancer history, or progressive neurological compromise. Similarly, a CT scan is not the best diagnostic test to rule out gallbladder stones; an ultrasound test is not only better, but safer, as there is no radiation. It is also less expensive. Guidelines can help minimize inappropriate imaging. And adhering to such guidelines is standard practice in most jurisdictions. But Bermuda will only experience a greater control over costs if all insurers and providers adhere to them, not just BHB.
People in the community also need to get more involved in their care and educate themselves on health care practices that are high quality and safe. In the UK, a report on safety in the NHS has been undertaken by Professor Don Berwick, an acclaimed US expert who was director and co-founder of the Institute for healthcare Improvement in Boston and a previous health advisor to Barack Obama. Professor Berwick recently recommended that patients and their carers should be present, powerful and involved at all levels of heathcare organizations so that the patient voice is always heard. The Chairman has spoken about involvement in BHB governance and strategic planning, but this must also take place at the bedside, and in the doctor’s office. Berwick notes that this “should include participation in decision-making, goal-setting, care design, quality improvement and the measuring and monitoring of patient safety. Patients and their carers should be involved in specific actions to improve the safety of healthcare system.”
Hospitals around the world cost a lot to run – and BHB is no different. We are in ageing facilities that cost a lot to maintain, we have to provide a 24-7 service or access, not just in emergency, but in clinical support areas such as diagnostic imaging and pathology, in our Continuing Care Unit, in our acute care medical, surgical and psychiatric wards and in our mental health and learning disability group homes. BHB also requires huge support areas such as housekeeping, dietary, laundry, Human Resources and IT. But we know we can be more efficient and 10% has already been cut from budgets for this fiscal year, senior management salaries have been frozen since last year, and services are already being reshaped. Day care closed in the continuing care unit earlier this year, as did the daytime diagnostic services at the Lamb Foggo Urgent Care Centre. Full business cases are drawn up before any service is closed to ensure we not only understand the long term financial impact, but also so that the safety and care of the people who use the services is carefully considered.
In terms of strategic planning, the Board, staff and leadership are working on establishing new priorities, and we expect a very clear strategic path for BHB to be set in consultation with community providers, physicians, the Ministry, the Bermuda Health Council , insurers and service users. Over the coming months and years as a country, we must reform the healthcare system and the way our hospitals deliver medical and mental health services. However, we are absolutely clear on one thing: even though our most pressing challenge is financial, our most important and non-negotiable focus is on the integrity, safety and quality of healthcare services. And we will work with all our stakeholders, all the community, to achieve this. I would like to leave you with the words of Don Berwick in a letter he wrote with his report to the people of England as part of his report:
“You will have read much in the public press that may alarm you about the patient care in the English NHS…I assure you that the same can be said of every health care system in the world. Health care is complicated and, even when the staff and clinicians are doing their very best (which is most of the time) errors occur and problems arise for patients that no one intends…” Mr Berwick then goes on to say that the NHS “is capable of vast and continual improvement of safety, quality, patient-centeredness, and even cost, if, and maybe only if, everyone involved engages in learning every day. …Imagine an NHS where everyone, all the time, was part of that journey…all of you – patients, carers, and citizens have a vital and exciting role to play. Your voice is key to the future. I hope that this report will give you more confidence in speaking up everywhere and all the time…and will give those who care for you and want to help you the confidence and skills to invite you, hear you, and welcome you into authentic partnership.”
BHB similarly invites you to be a part of the change required in the healthcare system.

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