Letter from Minister Hooper 11/3/24

RE: Recovery & Reform Plan for Manx Care

Thank you for your e-mail of 29 February enclosing a document produced by IOMMS called “Recovery and Reform Plan for Manx Care”. I read this with interest but was somewhat surprised that it was also shared with all of Tynwald and the media. I welcome constructive engagement with anyone who has an interest in improving health and care services on the Island, however the sort of comprehensive engagement this topic merits is not best conducted via the media. 

In view of the now public debate your letter has generated, I am also making this response public in the interests of openness and also to set the record straight on a few of the misapprehensions within the document.

First of all, I welcome the overall sentiment that not only doctors but other clinicians and professionals play their part in helping to make decisions about how health and social care services are provided on our Island. I am pleased to see that you continue to engage with the Chief Executive of Manx Care and the Department’s door is also always open to those who have constructive ideas about how we grapple with some of the challenges that you have rightly identified.

I turn now to some of the points you have raised to clarify and also put straight some clear misunderstandings. 

Firstly, Manx Care was, in fact, established in April 2021 and has operated for nearly three years. You assert in your opening paragraph that the organisation has “overspent by £30 million in the 2023/24 financial year” and that funding is “primarily drawn from reserves and higher taxation rates”. Unfortunately neither of these statements are entirely accurate. 

Whilst it is the case that Manx Care is over-budget for this financial year, the reasons for this were clearly spelt out in the Tynwald debate, with the single largest factor relating to covering the extra cost of pay awards for hard working and dedicated front line staff across the organisation. The Treasury have recognised that the situation was more to do with structural funding issues, which they have made a significant attempt to correct with the 2024/25 budget by allocating an additional £43.8 million to the health and care service, rather than this being an issue of “overspending”. 

It is also incorrect to state this year’s additional funding to cover the over budget position was drawn from reserves or higher taxation rates – the over budget position this year was largely met from increased tax revenues, and the tax rate did not change during the year.  In fact, the total draw down on reserves this year was lower than originally budgeted for, even accounting for the supplementary votes.

Turning to your points in detail.

1.       Enhanced Political and Managerial Accountability:

It is worth remembering that the establishment of Manx Care, which has operational independence from Government, was instigated as one of the recommendations of Sir Jonathan Michael, a highly qualified consultant nephrologist and medical leader in the NHS in England. The Manx Care Act, which was approved by Tynwald has placed the operational delivery of healthcare at arm’s lengths from politicians. It is hard to see how the placing of a national politician (a MHK) on the Board of Manx Care allows for that operational independence and it would risk political interference in what are quite rightly decisions taken by the health professionals. MHK’s already have full access to Manx Care senior leadership, with frequent briefings and engagement facilitated by the Department. Tynwald Committees can, and do, call Manx Care leadership before them to give evidence and answer questions directly. 

The Mandate from my Department is a comprehensive document and fully reflects the political priorities for health and social care on the island as set out in the Island Plan by the Council of Ministers and approved by Tynwald. I would encourage you to refresh yourselves on what is in the Mandate, as we have recently published the 24/25 version along with a budgetary envelope for the year that genuinely reflects the financial pressures that Manx Care has experienced in the current financial year. The Manx Care Board is already working to a clear Mandate from the Government that is aligned with DHSC strategy and policy.

2.       Establish a medically led governance structure, supported by global evidence indicating improved performance and safety.

I agree that as an integrated care provider, Manx Care needs strong clinical and professional leadership. As Manx Care’s responsibilities include the provision of primary care, secondary care and social care, delivered through a range of clinical and service models, the professional and Board leadership needs to reflect this broad range of responsibilities, and not be driven by a “medical majority”. 

The Manx Care Board has a wide range of qualified clinical members to ensure they can deliver effective clinical leadership across their entire range of responsibilities  As well as clinical leaders the Board also includes Members with other professional experiences, such as those with a financial background.

Manx Care is also structured as a “unitary board” where Executive and Non-Executive Members work in partnership, with the Non-Executives having a voting majority. This is considered “best practice” across the NHS and reverting to an Executive Board structure where Executive Directors make the key decisions as you propose would be a retrograde step.

I have enclosed as an appendix to this letter a detailed breakdown of the current Board membership, including information on their professional qualifications and experiences where relevant. As you can see, the majority of the executive members of the Board have clinical and professional backgrounds and the non-executive members each bring their own expertise in their fields. I would also draw your attention to the fact that we have recently appointed a new Chair of Manx Care, Professor Wendy Reid. Professor Reid is an experienced consultant obstetrician and gynaecologist, having also served a term as vice president of the Royal College of Obstetricians and Gynaecologists and worked as the medical director and interim chief executive at Health Education England. I can think of no one better qualified to provide leadership for Manx Care at this critical time.

3. Streamlined Management Structure:

Your comment that the current management structure is “top-heavy” and that management expenditure should be limited to 5-6% of the budget. 

You may be interested to learn that currently the cost of the “top” of Manx Care, its Board including all the executive and non-executive directors is around £1.2 million per annum. This represents less than half of one percent of the total Manx Care budget. Most of the rest of management within the organisation is undertaken by clinicians and professionals engaged on front line or support roles as part of their normal course of duties as you would expect with any organisation of around 3,000 staff. 

I have no intention of allowing an increase in executive management expenditure to balloon to a limit of 5-6% of the budget proposed in your letter. 

4. Transparent Reporting and Budgeting:  

Your comments about transparent reporting and budgeting were quite surprising.

Manx Care already reports on performance, quality and safety monthly and publishes this information on their website in the Integrated Performance Report. Further information is published as part of the Manx Care board papers as well as annual complaints and duty of candour reports. I have no intention of asking Manx Care to reduce the frequency of their regular reporting down to quarterly. 

In terms of the accounts, these are prepared and monitored by Treasury already through the Finance Shared Service and Financial Advisory Service. Budget proposals are already produced and submitted to Treasury annually, after having gone through a robust process between Manx Care and the DHSC, although in point of fact there is much more regular reporting and dialogue between the Department and the Treasury on financial matters. Reducing this to an annual exercise would be a significant backwards step. 

I do however welcome your suggestion for the inclusion of a broader range of metrics within the reporting framework and would be happy to discuss this with you further. 

5.      Comprehensive Workforce Strategy:

On the question of a workforce strategy, I agree that this is something that is clearly required. This is one of the actions of the Transformation Programme Workforce and Culture team to undertake assisting Manx Care and significant progress has been made on this already.  A Nursing workforce strategy has been developed.  A Recruitment and Retention Strategy is being developed and has been consulted on via the People and Culture Group and People Committee which has representation from the BMA/LNC. Partly as a result of this work the spend on agency staff has reduced by £2m over the last year as real progress has been made to recruit into permanent front line posts.

The BMA/LNC have been engaged in this work by the Interim Director of People who is coordinating this on behalf of Manx Care.  Progress is reported into the monthly meetings that are held with BMA/LNC.  As you can see, significant work is already underway working alongside OHR and staff side representatives and I would like to extend my thanks to you and all the staff that participate in this work.

6.      Fiscal Prudence:

In terms of financial management and cost control I would agree with your points. We do want to find ways of providing funding for those areas that need investment such as primary care and CAMHS but that has to be achieved within the finite resources that are available and this requires decisions about other things that could be deprioritised. 

It is worth noting that the costs per capita that you quote are not directly comparable, as Manx Care’s budget includes social care costs which are not included in the NHS budgets in the UK. When comparing to Jersey, it is also worth noting they have a part privatised healthcare system, and I will not support moves to privatise healthcare on the Isle of Man.

Prioritisation takes place through the Mandate framework and document which has been touched on earlier in this letter and investment in CAMHS and mental health are both referenced in the Mandate for example as areas of priority for the upcoming year. In addition the Transformation Programme which is transferring to DHSC from the Cabinet Office next month has at its heart the Primary Care at Scale project. The Board of Manx Care are focused on making sure that every pound spent goes towards front line services and have over delivered on their cost improvement targets every year to date. 

7.      Removal of Redundant Structures:

In respect of your request to disband the Transformation Board, Tynwald approved this last November and as mentioned above this is in the process of being disbanded and the functions moved to the DHSC.  The Health Services Consultative Committee (HSCC) is also already undergoing a process of meaningful reform, as was also supported by Tynwald last year. 

On your points about other “redundant” structures I must say I am a little confused about what you think this may achieve.

On the one hand you are suggesting the disbanding of the DSHC, but then also suggest the creation of a separate and distinct Health & Care Quality Commission. 

I think it is worth busting some common myths here. The Department of Health and Social Care has around just 40 staff who undertake a wide range of duties that are necessary for the operation of health and social care on the island, not just the regulation of all the health and social care services. The DHSC is also responsible for the development of strategy, policy and legislation as well as advising Ministers and Tynwald on matters relating to health and care. The Department represents about 1% of the total health and care budget.

These functions would still need to be undertaken wherever they sit within the health and care structure. You could of course move any functions to another Department or body however I do not see how this would make any material difference to the cost of undertaking these functions, nor does your letter explain this in any detail. I would be very interested to see the calculations you have undertaken to support your assertion that the functions of the DHSC could be undertaken elsewhere whilst generating “significant cost savings” as I am very interested in ensuring taxpayers’ money is spent efficiently and effectively.

It would also be highly unusual not to have a Minister or a Department that is solely focused on health and social care given that this represents around one quarter of government expenditure and is a critical priority for the Island as a nation. Your proposal that these functions should be subsumed into another Department or outsourced to a United Kingdom body, removing the direct line of accountability and responsibility to Tynwald is somewhat bizarre.

You also make reference to granting the CQC “statutory status”. You may be aware that the CQC is a statutory body in England, with a remit set out by the UK Health and Social Care Act 2008. It would not be possible for the Island to legislate to change UK law to extend the remit of the CQC to the Isle of Man, this would need to be done by the UK Parliament. Equally, the Island could not change the constitution and remit of the CQC through our own domestic legislation. 

The arrangements we have with bodies such as OFSTED or the CQC are contractual, with the Department retaining the regulatory responsibility and functions, this is in part due to the legislative set up I have referenced above, but is also due to this being viewed as the most cost effective manner of ensuring a robust regime of external and independent inspection. 

I do not consider it a good use of public money to create yet more administrative structures of our own when we can work effectively with others instead. 

In conclusion then, I thank you for your letter and your interest in improving health and care services on the Island.

I know that I speak for both the Department and Manx Care when I say we are keen to work positively with everyone who shares this interest. To this end I suggest that discussion of your proposals and other areas of mutual interest continues at the regular meetings that are held with Manx Care. I would also be more than happy to meet to discuss any of your views or provide any further information you may require.

Yours sincerely

Hon. Lawrie Hooper, MHK

Minister for Health and Social Care