Bermuda shorts 2: a collection of firsts

by Bill Shields

14 July 2017

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.

Hello again from Bermuda. I’ve recently attended the US HFMA annual conference (its annual national institute) in Orlando – a not insignificant hop of some 1,000 miles.  It is my second time at this event, having attended as HFMA chair in 2009 in Seattle.

I may not be the first member of HFMA UK to join the American association, but I think I'm probably the first past chair or president. I have experienced many other ‘firsts’ since arriving in Bermuda, even for someone as long in the tooth as myself.

I passed my scooter driving test at the first attempt and bought my first scooter. And I wore shorts to work for the first time in my career despite swearing this would never happen. Unfortunately, I also failed my car test – twice in fact – and, in doing so, probably became the first person ever to do this by driving too slowly in a country where the maximum speed is 21mph!

You may have noticed Bermuda recently hosted the America’s Cup – and attending this amazing spectacle became another first for me. Ben Ainslie Racing, unfortunately, failed to mount an effective challenge to become the first British winners. And so, like the rest of the island, I cheered on Bermuda’s adopted Oracle Team USA as they fought for the ‘auld mug’ with Emirates Team New Zealand. That didn’t end well.

As I trailed last time, I also attended my first Public Accounts Committee with Bermuda Hospitals Board’s (BHB’s) chief executive officer. Members wanted assurance that a reduction in government funding for Bermuda Hospital Board in 2017/18 would not adversely impact patient care.

This was quite different from the UK version, being held in a church hall near the Parliament building and covered by one journalist. It quickly became clear from newspaper coverage in the days following that healthcare funding is not well understood in Bermuda and we have a major role in educating the country on how funding is raised, allocated and spent.

In Bermuda we have the Bermuda Health Council, an organisation that is part-regulator, part commissioner. It has started a process to determine how universal health coverage can be delivered in Bermuda without increasing the current monthly Standard Premium Rate (SPR) of $334. If you were paying attention last time, you’ll know this is the price of the minimum health benefits package (known as the Standard Health Benefit or SHB) that must be included in every health insurance policy sold in Bermuda.

The council has estimated that the most comprehensive definition of SHB would cost $440 per person per month. With the government committed to no increase in the SPR, for an insured population of around 49,000, this equates to a shortfall of around $50m. That presents an interesting challenge that will be all too familiar to practitioners in the NHS. This raises questions as to what should and shouldn't be covered as the standard offering in a modern developed country.

Running alongside this, BHB is developing its own clinical services plan. This will outline what we should provide and what should be provided by other providers or off the island in the US. We are also considering what treatments currently being provided in the US could be provided cost-effectively and safely in Bermuda.

BHB continues to develop and implement its deficit budget for 2018 and is now in the process of rolling out a financial recovery plan as part of its medium term financial strategy to ensure this will be delivered. For the organisation, this has proved to be another first: while savings of quite a significant scale have been made in the past, these have tended to be piece-meal in nature, have not differentiated between cost-reduction and avoidance, have barely touched workforce savings and have had a significant bias towards revenue increases.

Workforce savings in particular will be a massively complicated issue for one of the island’s main employers, given that alternative employment is difficult to come by and insurance coverage is almost always through employers.

A programme management approach and appropriate governance arrangements will clearly be key to our success in this endeavour.

In a further reflection of events in the UK, Bermuda is in the midst of its own general election campaign, with the vote due to take place on 18 July. Unlike the UK, however, health has not, historically, been a major electoral issue, coming a long way behind the economy, employment and education.

Signs so far suggest this year’s campaign will prove to be no different. But I’ll report back next time and let you know how the whole election experience differs from the way things are done in Westminster.

Until then, good day!

Bermuda shorts 1: the heat is on
Bermuda shorts 3: putting the focus on costs