JERSEY’S healthcare system needs to be “redesigned” and aligned with an English hospital, a senior consultant brought in to drive improvements has said in his damning post-mortem of his experience in the department.
Professor Simon Mackenzie, who came to the Island in January 2023 as the clinical lead in a five-person “change team”, spent an hour yesterday morning painting a picture of a broken system resistant to change.
He said it needed to make “difficult decisions” to ensure it could provide a sufficient standard of care to Islanders, both now and in future.
He said his experience was “bookmarked” by consultants repeatedly rejecting the findings from Royal College of Physicians reports and barely adhering to accepted guidelines, an attitude he said he had never encountered anywhere else.
Prof Mackenzie was appearing at the first of three hearings between the Health and Social Security Scrutiny Panel and former senior officials of HCS, with the hearings intended to prise out any “lessons learnt” that could be used to improve the service.
Tom Hayhoe, who was chair of the department’s advisory board for five weeks, also testified frankly about the state of HCS.
Both experts – who were brought in after a report by Professor Hugo Mascie-Taylor found serious issues with governance at the Hospital – admitted that if they were Jersey residents, they would seek healthcare away from the Island.
Their summaries delivered an ultimatum for Jersey’s healthcare system: it needs to fundamentally “redesign” itself, either by becoming an arm’s-length organisation, being managed by an external contractor or latching itself fully to another facility.
Professor Simon Mackenzie
Prof Mackenzie – an expert with almost 40 years’ experience working in healthcare as a clinician, executive and non-executive – did not hold back when asked to lift the lid on HCS.
It is the first Islanders have heard from him since he confirmed his resignation from the “change team” in May, citing a lack of support from the Health Department in his resignation letter, something which Health Minister Tom Binet has publicly disputed.
While he did not discuss the reasons for his departure from his consultancy role, he gave a blow-by-blow account of his time in the post.
He began by saying that while his brief had been to improve clinical governance, “it became clear almost immediately that people had concerns about the quality of care”.
“We shared those concerns and felt professionally obliged to address them,” he added.
He referred to several Royal College of Physicians reports, one of which was from 2014, which had made recommendations that had not been implemented.
“I could not find any evidence for action between 2014 and 2022,” he said. “I do not believe that care in Jersey is better than most places. The standard of healthcare in HCS is generally lower than the standard I would expect to see in a similar-sized NHS hospital.
“I have told both health ministers, going all the way back to July 2023, that knowing what I know, if I were a Jersey resident, I would choose to have my healthcare elsewhere.”
“An attitudinal challenge”
Prof Mackenzie said that when it came to making improvements, “it was difficult, because fundamentally a lot of the consultants did not accept the findings of Royal College reports”.
“It’s not something I’ve encountered elsewhere. One consultant even said in an open session that the Royal College should have never been allowed to come and scrutinise them,” he said.
“That element of denial made it very difficult. The real challenge was an attitudinal one.”
He added: “There needs to be a fundamental change. There are ingrained attitudes among the senior medical staff which percolate over into the population that, on the basis of no evidence, but just of their own self belief, they are good.”
Maternity
When pressed to find some positives, Prof Mackenzie admitted that “some progress has been made in maternity”.
However, he added that this was “helped along” by the recent inquest into the death of baby Amelia Clyde-Smith, which – after an investigation by the Royal College of Obstetricians and Gynaecologists identified “missed opportunities” – found that the tragedy was “probably avoidable”.
Prof Mackenzie said: “The pressure of having to face public scrutiny allowed us to put some force into addressing the issues of that case. But it required a degree of persistence that was surprising.”
What needs to happen
Prof Mackenzie said that several changes to administrative arrangements were needed.
“The people of Jersey would be better served if you allowed managers to manage. There is not too much management in HCS, there is insufficient effective management,” he argued.
“Before I arrived, I thought that because it was a small organisation, it would be easy to make things happen quickly. It was anything but. I can get things done faster in a hospital in England.
“HCS cannot decide how it wants to prioritise its HR and finance, and everything has to be put out to the government. I would make it autonomous, like Ports of Jersey, and have it run separately, so that it is not a part of the civil service.”
Prof Mackenzie continued: “One thing that the organisation lacks internally is an operational plan which looks at what we need to do this year, whether we have the resources to do that, what our alternatives are, what the knock-on consequences are.
“You’re providing some services in HCS that you should not be providing in the Island, because I don’t believe you have the scale to do it. This also means that you have too many consultants who are the only consultants here in their speciality, which I would not want.
“Your consultants should be working in networks with larger groups of consultants at other hospitals. We should pay for consultants to have two weeks a year working in another centre to build that expertise. It would be great if you could persuade one of their consultants to come and work in Jersey for a few weeks, to get that relationship going.
“If I was redesigning your system, and I think it does need to be redesigned, I would do one of two things.
“Option one is to align the service formally to a UK centre. This could be an NHS hospital, in Southampton or London, or a private-sector organisation.
“The centres we currently use are often based on personal connections. It is all a bit chaotic and I would dispute the myth that you have bargaining power through your additional income to these hospitals. HCS’s entire budget is less than the budget of these organisations.
“I would recommend a single contractual relationship with a larger organisation.
“Option two, if you want to be radical, is to contract HCS out to an organisation. I accept the political reasons that you wouldn’t want to do that, and it would involve writing very tight specifications.”
Prof Mackenzie said: “You need to accept that you have a problem. You can’t hang it on any specific generation of managers. Replacing the people is unlikely to give you much change. The system that you have has pushed people into this. My regret, looking back, is why did I not achieve as much as I’d hoped to achieve. It’s partly that the system is designed, not intentionally, to produce what it produces. You’ve been around this loop a few times in Jersey, that’s my impression.”
Tom Hayhoe
When Mr Hayhoe took up his role as chair of the HCS advisory board in February, he brought with him more than 35 years’ experience in health leadership, including time as chair of West London NHS Trust and West Middlesex University Hospital NHS Trust.
Like Prof Mackenzie, he fired parting shots at Deputy Binet when leaving the role after only five weeks.
Mr Hayhoe’s hearing, less than half an hour later after Prof Mackenzie’s and before the panel – consisting of Deputies Jonathan Renouf, Lucy Stephenson and Philip Bailhache – could get their breath back, covered many of the same points as Prof Mackenzie’s.
“The convention was cover-up”
He said: “The culture within HCS is massively hierarchical with, dare I say it, insufficient respect for the professions outside medicine, like nurses, pharmacists and therapists.
“HCS does feel to me like a service that I would have been involved with in the 1980s, compared to what I expect with modern medicine.
“I also didn’t have a sense of any respect for the sorts of things which add up to good clinical governance, like attitudes to medical appraisal. I heard things about a degree of lip service being paid to those.
“From raw data, I also had a sense of a culture in which there was no appetite to report incidences, and the convention was cover-up, rather than saying something had gone wrong. The tendency is for people to pretend that it didn’t happen.”
The board
Mr Hayhoe further raised concerns about how the advisory board had been set up and whether its current model and make-up had made it effective.
He added that it had created “severe confusion” over who was accountable to who and said that the board’s responsibilities and its structure needed “serious consideration” if it was renewed.
What needs to happen
“Jersey has to take some difficult decisions about what things are done on and off Island,” he said.
“The clinical governance and oversight of a service in the UK is the obvious one. In an ideal world, I would like to see clinical leaders and consultants in Jersey regularly spending a month on exchange with a clinician in another UK hospital, because it would help them to keep abreast of good practice.
“The only sensible way of doing it would be to partner with a single, well-run, large university institution in the UK.”
He further supported an “exchange” of consultants between Jersey and other institutions but added: “This relies on consultants themselves in Jersey being willing to engage with that process. There would be some who would be resistant to change on that sort of scale.
“I did have a real sense of a challenge in terms of morale in the organisation, and it would be nice for it to feel that it was on a path towards success as opposed to caught up in a political quagmire.
“You’ve got a challenge on your hands.”
Response from Health Minister Tom Binet
“Professor Mackenzie’s comments must be difficult to accept for the many people within the service who are doing a good job and those who are working tirelessly to bring about the numerous changes, the need for which is already well recognised.
“While I am not a specialist in any area of medicine, I have used the hospital services myself in the past week and I have found them to be efficient, effective and delivered with courtesy.”
