By Bernard Place
There are patterns in public service failure. They are not always obvious from inside the system, but they are often visible in retrospect – and sometimes even in advance.
Over the past two decades, organisations such as the King’s Fund, the Nuffield Trust and the National Audit Office have attempted to identify recurring signs of stress in NHS trusts that later went on to experience systemic failure.
Four markers appear again and again: persistent financial overspends; sustained operational difficulty meeting quality and activity targets; high turnover of senior leadership; and a major hospital redevelopment project unfolding at the same time. Jersey, though not part of the NHS, shows symptoms in all four areas.
The most visible of these is financial. The Health and Community Services department ran a £20 million overspend last year and is forecast to do so again this year. These overspends are not one-offs; they have become recurring.
At the same time, operational challenges – especially around long waiting times and difficulties in GP access – are widely acknowledged.
Meanwhile, the leadership of Health has been in constant flux. Within a single year, Jersey cycled through three chief officers, board members have come and gone and senior clinical and strategic roles remain unfilled or unstable.
Against this backdrop, the Health Minister has proposed establishing a new Islandwide Health and Social Care Board – alongside a separate board specifically for Health and Community Services – to strengthen system governance. But in the absence of organisational stability, these structural reforms risk adding complexity without clarity.
And then there is the hospital project.
Earlier this year, the Health Minister lodged an outline business case (OBC) for Jersey’s new hospital. The Scrutiny Panel tasked with evaluating it produced a report that raised serious and substantive concerns.
It was not just a political quibble over details. The report tested the hospital case against the HM Treasury Green Book – the UK government’s standard for investment appraisal – and found the OBC fell short.
In their words: “The evidence base for the preferred option…was significantly weaker than for other options considered”. They concluded that a proper Green Book assessment would not have selected the current scheme.
Rather than engage seriously with this analysis, the Minister issued a defensive response that brushed aside the core findings. He insisted that Scrutiny’s report failed to recognise the fundamental role of the Outline Business Case in the context of the development of a Jersey – as opposed to an NHS – capital project. In addition the Minister largely ignored the methodological concerns that had been raised. This may be a matter of tone, but tone matters. In cases of public sector failure, adversarial defensiveness is one of the earliest warning signs.
A further concern lies in the approach to regulation. Jersey’s Regulation of Care Law is being amended to bring hospital, ambulance and mental-health services within the scope of the Jersey Care Commission. This is a necessary and overdue reform.
But the normal Scrutiny panel responsible for Health is not taking the lead in reviewing the proposed legal changes. Instead, a sub-panel is being created. Some members say they lack sufficient knowledge to provide effective scrutiny, and others have declined to take on the work. This is an unusual step. At best, it suggests poor co-ordination. At worst, it suggests a dawning awareness of the political sensitivity – and potential volatility – of the coming months.
The Care Commission, for its part, has made clear that it will conduct its work with independence and professionalism. In its inspection framework, it describes itself as a “critical friend”, committed to identifying risks, but also to helping health services improve. It will not be looking to name and shame. But it will be looking closely.
It is worth pausing to ask what a constructive relationship with the regulator should look like. First, it requires respect – both for the process and the people involved. Second, it demands transparency and access to information. And third, it requires a willingness to hear difficult truths. No inspection process can guarantee perfection. But the best systems engage with inspection not as a threat, but as an opportunity for growth. A culture of psychological safety – where staff at all levels can speak up about risks or failings without fear of reprisal – is essential.
I speak from experience.
From 2000 to 2007, I was chief nurse and executive director of Maidstone and Tunbridge Wells NHS Trust during one of the most severe public health failures in modern NHS history. An outbreak of clostridium difficile infection led to patient deaths, and the Healthcare Commission’s report into the incident still stands as a benchmark of system-wide failure.
As a board member, I was personally accountable for care standards and patient safety. I resigned my post.
At the time, many of the same signs were present: overspends rationalised as necessary, leadership turnover dismissed as coincidence, operational backlogs treated as temporary, and a large capital project pursued with intensity.
The most damaging dynamic was not that we didn’t know the risks – but that we did and failed to act. We convinced ourselves they could be managed. The late warning signs were softened or minimised. Some of us believed, against our better judgment, that the worst wouldn’t happen.
Business leader Margaret Heffernan calls this “wilful blindness” – the act of turning away from uncomfortable truths, not because they are hidden, but because they are hard to face.
The greatest risk to Jersey’s health system today is not any single failure, but a refusal to look squarely at the interlocking pressures that are building.
This article is not a claim that Jersey’s health system is on the brink of collapse. It is a call for vigilance, transparency and humility. We have a chance to avert the risks. But doing so will require a cultural change in how we lead, how we scrutinise and how we relate to the public.
The minister and his senior team would be wise to approach the upcoming Care Commission review not as a contest, but as a conversation. They should treat Scrutiny as a partner, not a problem. And above all, they should resist the urge to press ahead with large-scale structural change without a clear-eyed reckoning with operational reality.
Leadership is not about never being wrong. It is about recognising when systems are under strain and having the courage to correct course before harm is done. The signs are not yet irreversible. But they are familiar.
A registered nurse for nearly 40 years, Bernard Place has been a clinician, teacher and researcher in intensive care units. From 2012, he managed departments in Jersey’s healthcare system and from 2015 to 2019 was the clinical project director for Jersey’s new hospital.
