Chairman, CEO speak at Sandys Rotary

Jonathan Brewin, Chairman:
I would like to thank Sandys Rotary for giving me this opportunity to talk to with you about our hospitals and our healthcare services. I would also like to introduce the BHB CEO, Mrs Venetta Symonds, who is with me this evening.

There is very little that goes on at our hospitals that doesn´t end up as a leading story in the news, so while I doubt I can tell you something new, I do hope I can provide some context and colour to the challenges and opportunities that we are facing at BHB. Each one of us takes our health seriously. It is our most important possession.

Likewise all of us at BHB take our responsibilities to provide our fellow Bermudians the very best of care when they are at their most vulnerable. So in that context I´m not going to be subtle about the key point I would like to make tonight.

Change is not just needed in the health care system in Bermuda. It is unavoidable, if we want modern, financially-sustainable and affordable services which genuinely put the patient first. BHB is already setting its sight on modernizing its services, governance and operations, and I am looking forward to sharing more with you about this tonight. But if only BHB evolves, and the private health system does not, costs will still spiral and patients will not receive consistently high quality care at best value. We cannot make the changes needed alone.

I might as well start where the big news is and talk about BHB ceasing to provide urgent care services from the Lamb Foggo Urgent Care Centre. Let´s start with the reason for ceasing the service. BHB will possibly be heading into debt by the end of this fiscal year and the urgent care centre averaged a loss of about $250,000 each year.

I have heard it asked a few times why shouldn´t BHB ´t just absorb the loss, for the common good? Well, BHB is already absorbing a $14 million loss on its Continuing Care Services, as government ceased paying for residents this fiscal year. It is for the very specific good of this vulnerable population in CCU that we keep the service running, despite our Long Term Care services running at a $12million loss this year. Our residents have nowhere else to go, and the safety of our patients and residents is the most important thing we strive
to achieve.

But what about the safety of the people in the East End? Well, most of the 14 people a day who accessed the urgent care centre had minor ailments that could either be appropriately managed by their GP, or would not be made worse by the 15 to 20 minute drive to the Emergency Department at the hospital. Quite simply, there are good alternatives and options for these people.

While we do recognize the safety implications of having a medical service in the east when the causeway closes, this is a rare occurrence. There will be less costly ways for this to be provided other than keeping the evening urgent care service running for a causeway closure that might happen once or twice a year. And there are major opportunities for us to work with primary care or other healthcare providers.

Finally, the cost of an urgent care visit to the patient is $422- the cost of a GP visit is half of that, and the cost of the visit to Emergency is about $270 for a very minor condition that does not require diagnostic tests. The high cost service lost money for BHB, and it cost the system dear. And we all pay for that in rising premiums.

The closure of this service is just the start of the process. BHB has to look at all the services it provides and ask the same questions- are we mandated by law to provide it? Are there better value options for patients provided elsewhere? Can we reorganize how we provide services and improve collaboration and coordination to reduce the costs of care for Bermuda?

The driver behind this strategic rationalization is financial- we are running out of money, just like many other private and public operations in Bermuda. The financial health of BHB is the Board´s mandated responsibility and I will tell you more about what we are doing to address it. The financial problems BHB is suffering relate to many things, including an increase in services that drove up costs and saw staff numbers rise from about 1,500 in 2007 to 1,850 today. The recently announced audit report reported loose controls that did not ensure best value. As mentioned, BHB lost the geriatric subsidy that paid for the $14 million a year Continuing Care service.

Finally, the establishment of revenue caps against a backdrop of an unregulated healthcare system meant BHB lost millions of dollars in providing services for which it could not be paid. In addition, BHB was notified in September 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. It is true that the commencement of the service payments for the new acute care wing will cause us even greater pain when they start next fiscal year, and there will be the operating costs related to the additional space.

If things do not change, BHB could be in debt to the tune of about $200 million over the next five years. If they get worse, that number looks even bleaker. BHB cannot afford to maintain the status quo. More importantly Bermuda cannot afford it. Since the Board was appointed at the beginning of this year, the financial issues have dominated. We have the benefit of reviews on our clinical and corporate governance, on our financial situation, physician compensation and the Auditor´s Report. The findings of these reports have a consistent message- BHB must modernize and implement best practices with regards to governance, financial reporting and clinical and operational decision-making. The benefit of all these reports, which are publicly available in summary form, is that BHB has a very clear roadmap of what it needs to do to meet these standards.

It was also gratifying to see reduced costs at BHB, according to the unaudited financials we released in October´s latest quarterly report. But revenues also dipped – this was the impact of BHB controlling the use of diagnostic services. It helps keep us within caps, but it hurts us and requires even greater pressure on driving down costs. BHB and Bermuda have to rapidly address the strategic reshaping of services and greater regulation of the system. This is needed to help us on the road to financial sustainability.

BHB needs to agree with stakeholders such as Government, physicians, the Bermuda Health Council and the general community what services it is best placed to provide at best value, and which services are more efficiently provided outside of BHB. Long term care is an obvious example, and great collaboration, coordination and communication is needed to ensure sustainable solutions that work for Bermuda are established. I have also established a BHB Financial Sustainability Steering Committee, which includes Board members, senior management and people from the community with economic, business and financial expertise. We will be making recommendations on greater efficiencies. A working group is also overseeing the implementation of the Auditor´s
Review recommendations.

This will strengthen governance and decision making at BHB and in the long run will help us run a much tighter, more efficient ship. We are being held accountable by the Auditor General, and will be making a report on our progress in December of this year. Greater regulation in the entire system will also improve BHB´s ability to gain a firmer financial footing. Mrs Symonds will speak to this in more detail, but I was very encouraged by the Throne Speech last week, which announced that there would be greater controls on people bringing in healthcare equipment to compete in the market. That is a good thing for Bermuda and will help control new services that are not supported by a definite need.

In conclusion, I want to assure you that the BHB Board which I chair is fully committed to ensuring that all Bermudians have access to high quality healthcare. The challenge we face is huge but we are undaunted
and stepping up to make the changes needed. I thank you and look forward to your continued support.

Venetta Symonds, Chief Executive Officer:
BHB and Bermuda is not alone in its struggle to establish a high quality affordable service. Many hospitals are struggling in the US, Canada and Europe in exactly the same way as we are in Bermuda.

Like Bermuda, many countries have built healthcare systems and hospitals in response to very clear needs. 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 spiralling 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. Our employed Cardiologists are seeking to improve care and outcomes and are able to provide more service on-island. 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.

BHB is ensuring tests are only carried out when they are supported by evidence-based practices and this avoids the cost of inappropriate referrals. For example, 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 if only BHB implements them, all that will happen is business will be directed to the unregulated private healthcare providers. And Bermuda loses out on an opportunity to control costs.

Hospitals are some of the most complex organisations and around the world cost a lot to run – and BHB is no different. We are in ageing facilities that increasingly 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 and now urgent care 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. We are going to move many acute care services into the new wing next fiscal year. Emergency, Diagnostic Imaging, Dialysis, Oncology, Day Services and the acute care wards will all transfer. This leaves in the current King Edward – Intensive Care, Maternity, the Gosling Children´s Ward, physiotherapy, lab services – including blood tests and the blood donor centre, outpatient physiotherapy, and beds for people who are no longer acutely ill, but who may require rehab or a safe place to be discharged.

There is a cost to us when the facility is complete in the service payments, and there are also greater operational costs in using additional space, with higher use of utilities and the need for more support staff such as housekeeping. A lot of work has gone into making the new facility highly energy efficient; for example, solar panels on the roof will heat the water for patient and staff use. But it will still increase our bills. And while the cost of new equipment was budgeted for and money set aside, these purchases are draining our existing cash balance significantly.

BHB has just completed a strategic planning process that involved over 200 staff members; there is a clear vision for us to provide safe, high quality, people-centred, compassionate health care every day, especially as we make difficult decisions. New priorities have been established to help us achieve this vision and we have set 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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