Recovery & Reform Plan for Manx Care/DHSC

Recovery & Reform Plan for Manx Care

February 2024

Executive summary:

Introduction: 

Established since April 2020, Manx Care has operated for two years in full form

following a year in shadow. Despite its inception with clear objectives, recent performance indicates

significant challenges. The Chair's initial stance emphasised fiscal responsibility, yet the organization

has overspent by £30 million in the 2023/24 financial year. Funding, primarily drawn from reserves

and higher taxation rates, underscores the strain on the healthcare system. While the pandemic has

impacted service delivery, other factors contribute to Manx Care's struggles. Quality, patient safety,

and organizational culture assessments reveal concerning deficiencies. Addressing these issues

demands a robust Recovery & Reform plan.

The Plan:

1. Enhanced Political and Managerial Accountability:

•Appoint an MHK nominated by COMIN as the Chair of the Manx Care Board, ensuring a Manx resident majority.

•Facilitate MHK access to senior management and clinicians, emphasizing accountability to constituents.

•Mandate alignment with Cabinet Office/DHSC directives, prioritising patient safety, quality, and service levels.

Medical Leadership: Recovery & Reform Proposal for Manx Care February 2024

2. Establish a medically led governance structure, supported by global evidence indicating

improved performance and safety.

•Formulate key decisions in consultation with the Medical Advisory Group, composed of senior medical leaders.

•Redesign the board composition to include a medical majority, fostering transparent decision-making processes.

3. Streamlined Management Structure:

•Overhaul the current top-heavy management structure, collaborating with medical professionals and patient representatives.

•Rationalize medical management positions to ensure efficiency and frontline staffing adequacy.

•Limit total management expenditure to 5-6% of the budget, redirecting medical and nursing staff to patient care roles.

4. Transparent Reporting and Budgeting:

Implement quarterly performance, quality, and safety reports akin to counterparts in Jersey, incorporating culture of care and staff engagement metrics.

•Present fully audited annual accounts and budget proposals to Treasury, ensuring transparency and accountability.

5. Comprehensive Workforce Strategy:

•Develop a workforce strategy in collaboration with HR and medical advisory board, aligning staffing levels with UK standards.

•Enhance contract terms and conditions to attract and retain medical staff, emphasising ommitment to the local community.

•Ensure recruitment practices adhere to Tynwald regulations and maintain professional standards.

6. Fiscal Prudence:

•Allocate funds efficiently, prioritising underinvested areas such as Primary Care and CAMHS.

•Redirect resources to frontline services, addressing longstanding vacancies and reducing agency spending.

•Establish proper accountability mechanisms to monitor fund allocation and expenditure.

7. Removal of Redundant Structures:

•Disband redundant structures such as the Transformation Board and reassign DHSC functions to the Cabinet Office or Manx Care.

•Consider establishing an independent Health & Care Quality Commission in partnership with regulatory bodies in England or Scotland.

•Reallocate funding from disbanded structures towards critical areas such as recruiting more GPs and bolstering Public Health initiatives.

Conclusion: Manx Care's journey towards becoming a leading provider of quality, affordable, and safe care necessitates immediate action. By implementing comprehensive reforms and investing in key areas, Manx Care can transform into a functional, efficient, and patient-centric organization. A well-resourced primary care setup, supported by specialist services and robust governance, will ensure optimal healthcare delivery tailored to the needs of the Isle of Man's population.

Background:

Manx Care has been in existence since April 2020, a year in shadow form and two years in full form. How has it performed against its objectives? The (late) Chair Mr Andrew Foster declared at the outset that it would be seen as a failure if Manx Care overspent. In 2023/24 financial year Manx Care has overspent £30 million. The higher taxation rate has been increased in this year’s budget and the Government has drawn down from reserves mostly to fund Health & Social Care.

Looking at the quantity of service provided, Manx Care has fallen behind (the Pandemic is responsible for some of this backlog, but not all. Looking at Quality & patient safety, MC is not faring much better. A very important area that determines the success or otherwise of a Healthcare organisation is its Culture of Care. Unfortunately, in all the objective assessments undertaken so far (Culture of Care Barometer survey X 2, CQC reviews and ‘Have your say’ survey) it is obvious that MC does not have a healthy culture. Staff engagement which plays a significant part in determining culture is also at an all-time low. Whilst there has been a large proliferation in the number of non-patient-facing, managerial positions, there is a serious dearth of funded medical and nursing positions, compounded by the unfilled funded posts. There has also been a slippage in professional standards (appointment to consultant posts of doctors who are not fully qualified, provision of care by non-doctors without making it explicitly clear to patients etc.)

We are concerned that Manx Care is on a path to spending more and more with diminishing quality and throughput unless a strict and comprehensive Recovery & Reform plan is implemented.

The Plan:

The following are the themes for changes that we believe are necessary to reform and recover Manx Care and make it a successful, safe and cost-efficient organisation

1. Local political & managerial accountability

It is paramount that Manx Care Board is chaired by a political appointee (An MHK nominated by COMIN) similar to IOM Post and Manx Utilities. The Board should have a Manx Residents majority. Also, MHKs who represent their constituents should have the access to senior managers and clinicians where appropriate. We must not forget that we are all accountable to the public who are represented by

their elected representatives. The mandate must be produced by Cabinet office/DHSC and must ensure that neither patient safety & quality, nor the level of services provided should be compromised

2. Medically led organisation

There is good worldwide evidence that medically led organisations perform better and are safer. There is also evidence that the success of a healthcare organisation is directly related to medical staff engagement. Therefore, the board has to have a medical majority and the key decisions must be taken by the executive directors’ group on the advice of the Medical Advisory Group consisting of senior medical managers leaders and the decision-making process clearly and transparently mapped and documented. For example, the MC board could look like this: Chair: An MHK nominated by COMIN. Medical members: 2 Appointed by the Chair (we expect these to be MD & Deputy) and 2 nominated by the IOM Medical Society (one each from Primary & Secondary care), non-medical members-4- appointed by the Chair and CEO, all the while maintaining a medical and Manx resident majority.

3. Lean, responsive, honest & transparent management structure (medical & general)

The current management structure is clearly not fit for purpose and is perceived as being ‘top-heavy’ and removed from frontline care providers. A fundamental redesign of management structures with clear lines of accountability and responsibility to be undertaken in collaboration with doctors and patient representatives. Currently there are 30+ medical managers (Associate, clinical and deputy clinical directors) in addition to more than that number of non-medical managers in Noble’s alone! An efficient medical management structure should have less than half this number for the whole of Manx Care. The total management expenditure must remain between 5% and 6% of the total budget for the organisation. The doctors and nurses relieved from managerial roles should return to the frontlines where there are shortages

4. Manx Care Exec Team to produce a quarterly performance, quality & safety report

including a comprehensive dashboard highlighting key performance indicators such as our counterparts in Jersey produce: https://www.gov.je/SiteCollectionDocuments/Government%20and%20administration/R%20Quality%20and%20Performance%20Report%20-%20May%202023.pdf , but including culture of care and staff engagement indicators also. In addition, fully audited annual accounts and fully costed budget proposal for the following financial year must be presented for approval in time for submission to the Treasury. Manx Care do produce data on a regular basis, but they are not necessarily meaningful or relevant.

5. A robust Workforce Strategy (medical, nursing & allied) to be drafted with help from HR and medical advisory board ensuring appropriate levels of staffing at least on par with UK standards (Royal Colleges) and a clear operational plan to fill the roles with substantive staff rather than depending on locum & agency staff. One of the ways this can be achieved is by ensuring that our basic contract, terms & conditions are the best in the British Isles, including a government-provided indemnity cover that is

non-inferior to NHS England Crown Indemnity for medical staff, reopening the Private Patients Unit for the provision of healthcare to Manx people by Manx doctors etc. Recruitment & Retention are equally important. Retention and Recruitment: urgently develop a robust open transparent policy that values commitment to the local community, loyalty and local investment while eliminating the current trend towards negotiation, holding the organisation to ransom, manipulation and short-term opportunism (which blurs into cronyism and corruption) There are very easy mechanisms that can drive such a process such as staged retention incentives at 10 and 20 years of service. The UK has 3.18 doctors and 7.78 nurses per 1000 population. To achieve similar, we need 270 doctors and663 nurses in the Isle of Man. There should be Zero-compromise in the maintenance of standards; for example, only those with UK specialist registration should be appointed to consultant positions in the Isle of Man as per Tynwald regulations. Primary care services to have a regulated minimum GP staffing level. Consolidate GP services based on population in areas. Allied Health Practitioners and PAs should practice within their level of training and have a named supervisor, and robust Governance arrangements. Some further very useful advice contained in the accompanying document from doctors working for Manx Care.

6. Fiscal Prudence:

The Isle of Man DHSC has an annual expenditure of £313,780,000 (plus £ 2900000 overspend) which works out at £4082 per capita (£4294 including money spent on Synaptik). In comparison, Jersey spends £2729 per capita per year. UK Government spends £233.1 Billion per year, which works out at £3,477 per person and Scotland spends £3782 (highest in the UK). Jersey utilises private practice much more effectively (Annual income 6.8 million) and pays the best public sector pay for doctors and nurses in the British Isles, thereby achieving much reduced vacancy factors and therefore less agency and locum spend and overtime (their locum and agency spending less than half of ours). In short If managed wisely, the current allocated budget should be more than adequate to fund a safe, effective and efficienthealth&care system for the island. Funds must be allocated properly and accounted for correctly. The longstanding underinvestment in Primary Care and CAMHS must be corrected and foresighted investment into these areas of healthcare that will form a strong foundation for the overall healthcare system for the island. Between 10% 14% of the health budget must be allocated to Primary care (Royal College of GPs recommendation) and a vast majority of this must be spent on frontline doctors.

7. Removal of redundant structures:

Once the above measures are implemented, the Transformation Board and a vast majority of the current DHSC can be disbanded, leading to significant cost savings and efficient functioning, particularly if the CQC can be engaged to regulate healthcare on the island and can be granted statutory status. Most of DHSC’s functions can be undertaken by the cabinet office or allocated to Manx Care. Consideration should be given to the creation of an independent Health & Care Quality Commission which could regulate Health and Care on the island in partnership with the CQC in England or Healthcare Improvement Scotland and also replace HSCC (Health Services Consultative Committee) on the island. The PCN can be safely disbanded and the funding redirected towards recruiting more GPs. ThePublic Health Department should be adequately staffed and remain with the Cabinet Office and should fulfil the pillars of public health: Surveillance and epidemiology, Environmental health, Health promotion and disease prevention, public health policy and guidance, Health equity and social determinants of health and Diverse partnerships and innovation.

Conclusions:

Manx Care has the potential to be a leading provider of high quality, affordable and safe care, if appropriately managed. In summary, as well-resourced primary care set up led by doctors, supported by a consultant led specialist suite of services for secondary care, a safe and safely staffed inpatient service and fully contracted tertiary service that is tailored to the needs of the island's population will lead to a patient-centred, medically-led and management facilitated organisation that fulfils the health and care needs of the island’s population in a safe and sustainable way.

Prepared by the Executive Committee of the Isle of Man Medical Society