Bermuda Shorts 19: lockdown diary 2

by Bill Shields

07 July 2020

In April 2017, after 30 years working in NHS finance, former HFMA chairman Bill Shields moved to Bermuda as chief financial officer of the territory’s hospitals board. In this series of blogs, he documents his experiences.

Bermuda is now slowly moving into the final stages of a four-phase plan to reopen the territory. This has seen the extension of retail and hospitality opening as well as resumption of a full public transport service. Government advice for non-essential workers is that they can now return to work and commercial flights have resumed in a small way.

In the end, I spent three weeks in quarantine and isolation, convinced I had succumbed to coronavirus (see Lockdown diary 1). However, on returning to work, I had two antibody tests – both of which proved to be negative. Presumably, hay fever and hypochondria can mirror Covid-19 symptoms!

My wife Avril, who looked after me while I was suffering, proved to be less lucky and has actually tested positive for antibodies. How stupid do I feel!

Bermuda Hospitals Board (BHB) has faced many of the same issues as NHS organisations during the pandemic, particularly in procuring personal protective equipment (PPE) and ventilation. This has been further complicated by concerns over oxygen supply if we experience a surge of patients requiring high-flow oxygenation, for example through continuous positive air pressure (CPAP) devices.

In Bermuda, where there is no back-up, exceeding the oxygen supply limit would be catastrophic. While we safely managed our first cases, we are now awaiting the arrival of two oxygen concentrators from Canada to enable BHB to cope if there is a future Covid-19 surge.

PPE, as you will all be aware, has proved difficult to procure given the worldwide shortage of supplies. However, this has been particularly difficult for us because of Bermuda’s proximity to the US, where an embargo was placed on external exports by the Trump administration.

Periodic shortages of all surgical masks, procedure masks, FFP2 masks, disposable gowns and powered air-purifying respirators have required procurement staff to look beyond historical supply chains and existing vendor relationships. This has led to increased utilisation of equipment manufactured in China. Equally, the requirement, often, to pay up-front, vastly inflated prices has taken a heavy toll on short-term cash balances.

Staff have faced significant pressures. For a start they have had to get to work when there has been limited availability of public transport. They have also had to work longer hours, due to colleagues being quarantined, and often wearing uncomfortable PPE. This has been further exacerbated by the fact that the majority of clinical staff are non-Bermudian and are unable to see family and loved ones, who are often thousands of miles distant in countries with much higher Covid-19 incidence.

Fortunately, as previously reported, BHB is paid a fixed revenue sum for the services it provides. While this has caused some difficulties in the past, as this budget does not flex upwards, it has provided some safeguard during the pandemic where elective activity was halted for almost two months.

This is not, however, a sustainable position as the fixed revenue sum is, ultimately, sourced from health insurance contributions, which are, predominantly, collected by employers. Like many countries, the pandemic and lockdown have led to contraction of businesses. Many employees have had their health insurance premia covered during this period, where they have been laid off or furloughed. However, it is likely that there will be an overall reduction in the risk pool of as much as 15%.

Unlike many other developed countries, the government of Bermuda cannot resolve this problem with quantitive easing by injecting liquidity into the economy. As a jurisdiction dependent on the reinsurance industry, maintenance of a high credit rating is paramount.

BHB’s fiscal position is likely to be further impacted by the reduction in tourism. Unfortunately for those involved, visitors can end up as patients in our facilities and this has become a significant source of revenue in recent years. With basically no commercial flights or cruise ship visits this year, the impact is likely to be considerable.

Like many healthcare providers in the US, where a similar health insurance system operates, BHB will have to focus on its cost base as this wave of the pandemic comes to an end. As always, this cannot be at the expense of service quality, particularly given that the risk of subsequent waves of the virus could increase as the island opens up.

Instead, BHB is looking forward to constructive discussions with the Ministry of Health and the wider government about healthcare funding models, and potential integration solutions. These discussions also need to cover ways in which healthcare can be offered to the increasing number of under and uninsured individuals in the country.

These may appear daunting issues to navigate but, like many countries, the opportunity that this crisis brings to rethink and reshape the service offering is one we cannot afford to slip by.

The future will be anything but boring and I will keep you apprised of developments.

Until the next time, good day!



View all Bill Shields' Bermuda shorts blogs