Bermuda Shorts 20: my new normal

by Bill Shields

12 October 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.

It’s been a long summer here in Bermuda and there have clearly not been enough new experiences for me to have this year. In late June, after 33 years working in and around healthcare with nothing more than a few outpatient diagnostic tests, I managed to get hospitalised for the first time!

After my conviction that I had contracted Covid in March, I initially wasn’t too concerned when I started to get stomach pains in mid-June. When this turned into full blown D&V, I assumed it was a mild case of food poisoning which would pass in 24 hours or so, as has always been the case in the past. Over the course of the next week, however, I became more dehydrated, lost 10 pounds in weight, had two further Covid tests, an ultrasound, numerous blood, urine and stool tests and was diagnosed with salmonella food poisoning, which caused colitis. I then had a CT scan to determine whether my colon had become perforated. I realised this was a bit more serious than anticipated.

And so I found myself lying in the emergency department, severely dehydrated, feeling like I was 100, watching my blood pressure drop to 84 over 48, while my pulse was 100, running a temperature of 100.6 and waiting for my CT results, hoping I didn’t have sepsis.

The feeling of fear and helplessness, even for a reasonably well-informed patient is something I hadn’t anticipated. Although, I was very well cared for during my stay in hospital, I was in isolation for most of the time, first of all due to fears I could also have Covid-19 and then due to salmonella being transmissible. All clinical and support staff were in full PPE and no visitors were allowed for the first three days, which only added to my sense of being alone and completely helpless.

Weirdly, although this was a terrible experience, I’m really glad I had it. No amount of interaction with frontline staff, walk arounds, or patient interaction can give you a real sense of what it feels like to be a patient. Not knowing how ill you are, how long you’ll be in hospital and whether or not you’ll have a positive outcome. I’m not saying it was a life-changing experience, but it has definitely given me a new perspective on healthcare.

Sticking with Covid, Bermuda has done very well in its approach to tackling the virus. Following the initial wave when, unfortunately, nine people died, the government has adopted one of the strictest testing regimes in the world. All non-residents must have a test up to seven days before travelling to the island. They are then tested on arrival at the airport and again at four, eight and 14 days. All individuals must be quarantined until they have two negative tests and the process is strictly monitored through track and trace by the Department of Health.

Bermuda will not, however, escape the economic impact of the virus. Although tourism is less important to Bermuda than for the islands to the south in the Caribbean, it still accounts for 6% of GDP. The impact on the hospitality industry from both the lack of cruise ship activity and three months with no commercial flights has led to significant lay-offs. The full economic impact of this is difficult to quantify, but the government has already increased the debt ceiling by $1bn to $3bn and has just borrowed $500m of additional resource.

Bermuda Hospitals Board (BHB) is not immune to these changes. Last year $11m of our revenue came from overseas patients. This year we expect this to drop by $10m and this may be further compounded by the inability of government to fund all of the revenue received in FY20.

Our greatest pressure, however, relates to the increase in unemployment. Although BHB has a fixed revenue agreement with government, this is predicated on there being the same number of employees and employers paying into Standard Health Benefit, the government’s health insurance plan. Those payments have continued while staff are laid off and furloughed and this has off-set any reduction in revenue due to the need to cancel elective activity at the height of the pandemic. After six months of protection from insurance companies, however, payments will stop and this will have a significant impact.

Faced with a significant reduction in the current year, we are currently looking at all ways in which costs can be reduced in-year. The Bermuda government has done the same thing with all civil servants and is looking to reduce its pay bill by 10% for 12 months. Needless to say, discussions related to pay, while there is a significant risk of subsequent Covid surges and when other jurisdictions such as France and England have agreed pay increases for health workers is something of a challenge.

Our final challenge this year is one of cash. At the height of fee for service, BHB had nearly $120m in the bank, but this has been eroded with below inflation financial settlements and fee changes to where it is now below $40m and represents less than one month’s operational requirement. For those of you in the NHS who are used to a revolving working capital facility, this may sound like a very healthy position, but no such facility exists here. We have recently received approval to agree an overdraft facility – something BHB hasn’t traditionally required – and this is clearly a sign of the very changed financial circumstances we now find ourselves in.

As healthcare organisations continue to meet the challenge of this pandemic, while restarting elective activity, I will continue to keep you apprised of our approach on the other side of the pond.

Until the next time, good day!