Comment / Bermuda Shorts 26: the final cut

This is my last time writing about my life and work in Bermuda; as you read this, I am two months into my new position at Devon Integrated Care Board and it seems like the ideal time to look back on five and a half years in the strangest role I have ever had.

Bermuda is often referred to as another world, but nothing could have prepared me for the limited process and governance, both in Bermuda Hospitals Board (BHB) as well as Bermuda itself. I lost count of the number of times I was told that a peer-reviewed, evidence-backed process wouldn’t work by someone with no qualifications who had spent their entire career in the same organisation. This was actually a great learning experience for me as it has made me much more patient and nuanced in my approach than the Bill Shields who arrived in April 2017.

As I have mentioned before, at that time, BHB had not produced audited financial statements for six years following an investigation by the government internal audit service. I am very pleased to have completed so many sets of accounts to get up to date during my tenure. But this has also led to very strange discussions about post-balance sheet events, particularly referring to the impact of Covid-19 in the 2018/19 (FY19) accounts when it had yet to be identified. My arguments that this was ludicrous and there should be a six-month cut-off date from the date on the face of the accounts fell on deaf ears with the Office of the Auditor General, whose interpretation was that anything after the balance sheet date is a post-balance sheet event!

The constant pressure on resources is common, both to the NHS and BHB. What is different, however, is that the reduction in Bermuda has been an absolute reduction in revenue rather than flat cash or flat real. Again, I am pleased that BHB has managed to undertake real cost reduction and break even in each year since reductions began in 2017. Its ability to continue taking $30m plus out of the cost base is, however, not likely.

While the governing legislation requires BHB to set a balanced budget and break even, any organisation reliant on an overdraft to pay staff, is not a going concern and government will very soon have to either provide significant additional resources, allow BHB to reduce service provision, or allow consultation with trade unions to reduce the number of individuals employed. None of these options are palatable, but the ostrich-like approach to the financial problems facing the country’s only hospital have led to this very predictable outcome.

My other major focus for the last 18 months has been implementation of BHB’s electronic medical record, Pearl. This went live on 29 October and was the culmination of almost two years of preparation, system build, testing and training. Care will be revolutionised at BHB as it moves from manual, paper-based and legacy systems to full implementation of Cerner’s Millennium system across all services. To say this was a rollercoaster experience would be something of an understatement. My first programme director resigned halfway through the programme. There was a belief in government, without any supporting evidence, that a system could be delivered for a quarter of the cost. The advice received on interfaces, data migration and archiving was flawed. And it became clear during the build phase that there was a fundamental problem with the clinically driven revenue cycle module (a key component in any EPR designed to work in a fee for service environment).

Fortunately, we got an assurance partner, Channel 3, onboard. It undertook a gateway review that led to fundamental changes in programme structure and governance, appointed an interim programme director who was already working in the organisation and hired a very experienced chief information officer two months prior to go-live to support me as senior responsible officer.

No retrospective would be complete without mention of the pandemic. Bermuda initially fared much better than the rest of the developed world due to a complete lockdown. Even the airport was closed and army checkpoints restricting freedom of movement were in place. This position changed, however, with the Delta wave as reluctance in parts of the population to be vaccinated led to over a hundred avoidable deaths.

Within BHB, there was real fear among staff for their own safety, particularly when personal protective equipment was in short supply at the beginning of the pandemic. This was due to Bermuda’s traditional supply chain route being impacted by the Trump administration banning exports.

One major success during this period was the order and delivery of an oxygen concentrator from Canada to ensure the ability to provide high-flow oxygen to patients with Covid. This was the same time I experienced my only ever inpatient stay in hospital, when I contracted Salmonella. Hospital food has certainly not improved and this was brought into sharp relief for me after losing 10 pounds in a week. It was only after an intervention from a dietitian that I was given a nutritional supplement and gained enough weight to be discharged. For me, this demonstrates how a longer length of stay than necessary was caused by a non-clinical error.

When I first arrived in Bermuda, I encountered a slightly inebriated loss-adjuster who described the island in less than glowing terms as 60,000 alcoholics clinging to a rock. This is a major overstatement and was obviously said in jest. But drinking is a major part of the culture and is clearly, along with poor diet and higher levels of smoking than in other OECD countries, a major contributor to the high levels of type 2 diabetes, stroke and chronic heart failure – all of which are in the top three per capita. That said, I will miss spending our quiz winnings at Veuve Cliquot brunches with my quiz team colleagues!

Bermuda continues to lead the world in another unenviable statistic: per capita road traffic fatalities. Given Bermuda has around a thousandth of the UK population, the 17 deaths per year would equate to 17,000 if translated to the UK, rather than the 1,600 it recorded in 2021. This is all the more strange when one considers the speed limit is 21 miles per hour.

Despite the negatives, what are the things I will miss? First has to be the weather. It has been a huge shock to the system to experience again just how cold and wet winter is in England. I am concerned I will have to retire my sunglasses collection permanently at this rate! Second, I will miss the friends I have made and, in particular, the Highly Selective quiz team. Third, is the ability to travel to North America and be in Boston, New York, Miama or Toronto within two hours. Fourth, the amazing beaches and the ability to swim in the ocean in the winter. Fifth, my flat situated right above Hamilton harbour and hearing the water and the tree frogs every night. And lastly, the opportunity to work in a completely different jurisdiction, learn and develop towards the end of my career and change my life fundamentally for the better.

As I settle in at Devon, I know the challenges in today’s NHS are significant, but I am really looking forward to trying to make a difference to the patients and population we serve. I hope to see many of you soon.

Until then, good day!

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