Siobhán Fletcher sits down with Manx Care Chief Executive Teresa Cope to talk plans to slash surgical lists.
She responds to listener concerns and critiques from the Isle of Man Medical Society, and says 'unpalatable' decisions are 'necessary' to balance the books.
- Okay, as usual, if you could introduce yourself for me. - Teresa Cope, Chief Executive of Mancs Care. - So we're talking today about this Mancs Care decision to cut back on elective surgery lists. We've sort of had the Alhamard Medical Site point of view, they ran us through kind of what an elective surgery was, and that sort of thing as well. So I guess what led to Mancs Care to come to this decision, then how did you get to this point? - So at the start of the year, we knew that we needed to achieve around 19 million pounds worth of savings overall in order to not overspend in this financial year, and we were very committed to do that. So we identified 19 million pounds worth of savings, which was built up in a bottom-up way, working with our service teams in order to identify the savings for the organization, as well as sort of a corporate overlay of what else can we do? So the board in April signed off 19 million pounds worth of savings. Now, as we've gone through the year, we've had an increase in what we call our monthly run rate, so that's basically how much we spend every month. And that's been driven by the work that we send across to the UK, so our tertiary contracts, but also drug expenditure. And there's been a couple of very high-cost placements, and all of that has essentially meant that we have overspent on our monthly run rate. In addition to that of the 19 million pounds worth of savings that we initially signed off at the start of the year, some of those haven't come to fruition. Some of those have been subject to impact assessments, which means they're too risky to go ahead. And so the board is now in a position where ultimately of that original 19 million pounds worth of savings that we identified, 195 schemes, so a lot of individual schemes. Around 12 million pounds will be delivered in this financial year. Now that gives us a gap. So in July, we started working in order to close that gap, and that meant going back over some of the more unpalatable decisions and taking a closer look at where we can make those savings. And as a result of that, 4.8 million pounds worth of additional savings were identified and signed off by the Manx Care Board in September for implementation. And the elective cooling program is one of those. So with that 4.8, approximately three million pounds of that are savings which are not around frontline delivery and would have minimal, in fact no impact on patients. But in order to close that financial gap, we've had to take the really difficult decision as a board to implement some schemes, which we know will have a minor impact on patients. And we assess that. And that elective cooling program, it's an unpalatable decision. And we know the impact it will have. So in lots of respects, the Manx Care Board and the Manx Care Executive team agree with the position put forward by those two consultants who spoke this morning. It's not a position we would want to progress, but ultimately we have a commitment as a board to reach financial balance and therefore these decisions are necessary. So we've taken the decision to slow down some of our elective activity and take down some of those theatre lists. And that will happen from October and potentially could run for the rest of the financial year. We are hoping that as we recruit substantive staff and we expect to have those substantive staff in place by Christmas that we can re-look at this. So what was driving that decision around elective cooling was the amount of additional bank and low-income costs that we were incurring in order to run those full complement of theatres. So we took the decision to cool some of that activity and take those five theatre lists out around general surgery, gynecology and inos and throat. And as I say, this was absolutely done in conjunction with the frontline services. So it isn't a decision that the board made in isolation. It was absolutely done involving the clinicians and the teams. No one wants to take these decisions, but ultimately we have to. And in terms of orthopedics, that's more around saving high-cost consumable costs. So within that elective cooling, including orthopedics, there's a saving potentially for the full six months of around half a million pounds. So you say there that you discussed this decision with the frontline clinical staff. The Isle of Man Medical Society didn't seem to have that view. So what sorts of members of the frontline staff have you been talking to? So we have a care group structure. So we have a clinical director who heads up each of those care groups along with a general manager and usually a lead nurse. So as we were developing this, then that decision was primarily discussed with those individuals and cascaded through. As I say, we understand that this isn't a popular decision and it's not a decision we would ideally want to take. But what we've looked at carefully is the impact this would have on patients and how many patients could be affected. And if we were to enact this for the full six months, it would impact about 100 patients. Our theatre capacity is a very valuable commodity. It's a very expensive resource of any hospital, our theatres. And it is really important that we run those theatres efficiently. And what we are saying is the impact would be around 100 patients if we were to keep our theatre efficiency, the same level as it currently is. What we do know is there are opportunities to improve theatre efficiency on the theatre list that are remaining in place. And that's the work we are doing in conjunction with our clinical teams. So the impact could be less. And as we've discussed, if we have all of those new substantive appointments in place by Christmas, then we will have the staff to be able to not need bank and low-cum consultants in anaesthetics. And therefore, we can reinstate those lists. So it isn't about saying this is absolutely for the full six months. This is certainly what we need to do here and now. But we will constantly keep that position under review. There's a few things I want to touch on there. I want to kind of put some almost like listener questions and big questions from the public that I'm sure you've seen on social media as well to you there. Big one is early this year, income tax was raised from 20 to 22% with that generated money ringfence for health care services. I think a big question we get a lot of the time and we've seen a response to this store as well is that uplift was that being spent. Yeah, so obviously we started the year with a more generous budget and we were grateful for the uplift up to 347 million. That did reflect the outcome position. But even with that additional funding, we still needed to make £19 million worth of savings in order to balance our books. And just to put some context around that, for this financial year, a pay award for our staff, 44% will cost us £8.2 million. Inflation on the contracts that we hold on the patients that we transfer across to the UK on drugs and consumables will cost us a further £7 million. Because of the ongoing work of transformation, the non-recurrent funding that we had received comes to an end and therefore there was a further £3 million worth of commitment already built into our position. So you can see £18.2 million is needed for us just to stand still, you know, to give our staff a pay award, to pay the inflationary uplift on contracts and consumables and drugs and also to honour the commitments around the Sir Jonathan Michael's recommendations and those transformation schemes which now have transferred fully across the manx care. So I think it's an incredibly difficult balancing act because effectively, whilst we had all that additional money and that 20 million did come into manx care, we've needed £18.2 million, effectively just to stand still. That's without looking at additional demand on our services, any new services that we would want to provide or any responses that we would want to make over and above are existing plans for responding to things like the Care Quality Commission or Offstead Inspection. So whilst, yes, we had a lot of extra money and we're grateful for that, there is still an issue about what it truly costs to run the health and care system here on the island and that is part of the discussion we've been having both with the Department of Health and Social Care but also having the opportunity to present some of that into the Council of Ministers because we don't want to be in a position of constantly overspending but we have to sort of face the reality of ultimately, we will all collectively have to make some difficult decisions in order for health and care to operate within a budget which the island can afford to have. It's a very tricky question. When I think about the savings we're making, we're making them across the board, it's not, we're just making them on frontline services. We are looking at all of our, what would we consider, back office functions but also we have shared services so a lot of the areas where you could perhaps make savings on, say, infrastructure or IT or HR, those are provided to us by shared services so if we made a savings in those areas we wouldn't get the benefit of those and that's part of both the benefit for manx care but also a bit of a dilemma. I think the other thing I would want to say and again it's really positive. We have saved close to three million pounds in the last couple of years on reducing our reliance on agency staff and our bank costs have come down and that's really positive because we have been able to recruit into many of the post-substantively that were being filled by very expensive local and bank staff but the counter is that obviously substantive people, you can't change their contracts that easily. We have to go through a negotiation and we have to go through a process if we are going to change people's contracts. So whilst if you have an agency member of staff you can just stop their contract tomorrow we have reduced the number of agency staff significantly and therefore that doesn't give us the degree of flexibility to cut our costs. Health and care and the way we're structured were sort of almost 80% of our cost base is our workforce. And you mentioned there are three million saved in the last couple of years with regards to bank staff and we're talking about this issue of low-income staff as well. The number you're trying to save here is around £220,000 with the topic we're on today which in fairness formats care is quite a nominal number in terms of that big grand scheme of things of what you're trying to save. The ALMA Medical Society pointed out some things as well. I mean we're talking, it was £84,000 in the first four months of the year that the surgicalist was costing and that's the sort of saving we're looking at per month. Now if you add that all up it doesn't, it's more than the saving you're trying to make. Equally the ALMA Medical Society pointed out that you're currently trying to recruit for four major roles within the organisation, for example, Director of Nursing. And their point was if you just held fire on trying to hire them till the next financial year, you'd essentially save trouble what you're trying to save with this. Can you see why the public find it hard to rectify the frontline services being impacted and I completely understand what you're saying about all the stuff that's happened behind the scenes and the backdoor cost that the public aren't seeing. But this for them is a frontline service. I mean you mentioned about 100 patients, this might impact but that's 100 patients who might be in severe pain with the hip or their knee or you know and so on. So can you see the struggle the public have tried to almost, you said it was unpalatable, it's unpalatable for them as well. Absolutely, yeah no none of this is easy, absolutely none of this is easy. A couple of things, I mean as a statutory board we cannot function without a cheeseness who has accountability for the nursing workforce professionally and the same is true of the medical director. You know we cannot function statutorily without having an executive medical director and those are the two posts that I think are being referenced. We're also out to recruit to a people director but again it's unlikely that appointment will will hit before the next financial year but I but I do absolutely you know take the point around as needing to show transparency and and demonstrate equal scrutiny on non-frontline services and and as a cost base we have and we have shared all this detail. Our management costs are around two percent of our overall budget which is much less than the UK and HS and we have benchmarked that and looked carefully. I do think there are some further opportunities but equally what I want to focus on in ManxCare and we see so much opportunity regarding this is to become much more efficient. We see in efficiency everywhere and part of what we're doing including how we use our theatres is to make the resource that we have available to us and make sure we're using it as efficiently as we possibly can and we do recognise that it is difficult to change people's contracts. You know we we recognise that some of that some of those savings are around reducing non-clinical activity and so you know our medical colleagues have been asked to consider reducing some of their payments around non-clinical and we know that is difficult but that is the ask because ultimately we have a finite amount of resource and we have to demonstrate we are using what we have efficiently but we are absolutely looking at all of the posts that aren't front line and of those 195 schemes that we already have in train none of those are around reductions to front line provision we've absolutely looked everywhere else before we've reached this point. The only other thing that I would say with regards to elective activity and this is routine planned activity and we we do understand there is still an impact for patients but as we go into winter most hospitals choose to reduce their elective program because they will need the beds for the increased numbers of medical patients that are likely to come into hospital during the winter period we have a very small bed base here on the island and we have to work incredibly hard not to have delays in admissions and we work at a very high level of bed occupancy. Now what that means is often we have been in a position of having to cancel surgery electively in order to make room for our non-elective admissions so doing that in an unplanned way i.e. just cancelling people on the day is often the worst way it means that you waste a lot of resource and it also is detrimental to patients in terms of that cancellation and having to re-book so it is usual for hospitals through the winter period to really carefully consider a slight reduction in their elective program and so i think what we've done whilst we ideally wouldn't want to do it is is a sensible decision a given the financial position but given that we're going into winter without being able to put a lot of additional resourcing into our winter planning it is about doing things that we currently do more efficiently and more effectively in order to manage that safely through winter. You've just spent an awful lot of money reducing waiting lists that's been a big thing for max care and we've seen synaptic over for example and i mean i interviewed the nurse liaison for max care back in i think it was march time talking about how big of an impact that has for max patients and it's great big deal made of it when you're weighing up a decision like this how can you justify that that increase in waiting lists then after trying to bring it down so much yeah and and i know this this comes across as sort of a you know a decision which doesn't seem to stack up against the wider restoration recovery that got us down to sustainable waiting list levels and treated several thousands of patients and was a was a huge success what we're talking about here is across sort of four specialties a short-term measure which would impact a maximum of a hundred people what we do know is that our outpatient waiting times are very high and that's where we would want our clinicians to focus their efforts in place of doing theatre we know this isn't a long-term fix and we don't want it to be a long-term fix but in the short-term it's one of those necessary decisions that we've had to make and actually when we continue to focus on you know our theatre efficiency and improving our processes that level of recovery can happen quite quite quickly so you know i absolutely acknowledge this is not where we would want to be and this isn't a decision that has been taken lightly and we know it isn't without impact but we have to balance and and going into the winter period particularly i want to make sure our beds are available for the patients who will come into hospital over over winter and we can use the results we have effectively i mean just to pick up a one thing that you mentioned outpatient again when i spoke to the medical society they were saying this would have a two-pronged impact on waiting lists because you've got the people who's obviously their lists have been cancelled so you mentioned probably that a hundred um but then also if they're seeing outpatient clinics at the times where they should be normally in theatre then they could be adding how many people they see that day to the theatre list so it's almost a two-pronged increase in waiting lists yeah no absolutely the more out patients you do and depending on what your specialty is there will be a conversion rate to those people that need need surgery but you know in some of those specialties the number of patients waiting for surgery is actually quite low and the waiting times are quite good um so for example and i've been in the meeting with the team team this morning um there are 40 people on the waiting list for inpatient gynecology so actually it's a it's a relatively low number and that can be recovered quite quickly this is always about looking at the impact as we go through that piece of work but actually where a lot of our risk sits which is why there's been such a focus on us preparing the business case for restoration and recovery 3 which is focusing on the outpatient side of things is to to to clinically validate our list to understand who's on our waiting list and the urgency and i must stress in all of this urgent patients time critical surgery and emergency surgery will be completely unaffected and we are working really closely with the clinical teams to make sure that the impact on all of the patients who would ordinarily be scheduled for surgery is absolutely minimized again these elective surgeries essentially comes down to not being in emergency at the time what about if they're waiting on that list and the the issue gets worse while they're waiting and then that's a more complex and potentially expensive surgery down the line we wouldn't get to that point so for example if somebody if we needed an extra list to go in on a week because somebody need the surgery that week their clinical presentation had changed or it was a time critical surgery the list would go back in it's because of on the basis and the modeling that we've done at the moment those lists are being booked with routine patients but ultimately if we need two more lists of those five going back in in order to make sure say a cancer patient or a patient who needs time critical surgery those lists would go back in because the cost benefit analysis of that would absolutely demonstrate we need to put that put those back on and that's always been the premise of this and that's why we're monitoring it so closely that's why it's looked at on a daily basis and that's why we're working so closely with our clinical teams so in the specialties where we have taken the difficult decision the surgeons are determining which list go down and then which patients are prioritized and that's that's how we do things so ultimately the clinicians have have been you know no doctor no consultant is going to be happy about this decision and they they genuinely aren't but we've asked them to work with us we've asked them to do outpatient clinics rather than theatre on that temporary basis and we have asked them to help us select the most appropriate patients and manage that reduction and that cooling in the best possible way so we have the least impact on patients and that's that's how we should work our clinicians should be part of this um as I say you know no one is happy about this this decision but ultimately we have to make the savings and we also have to demonstrate we are using the resource that we do have as effectively as we can and what I do know is there are opportunities to improve our theatre efficiency here and Alfred Cannon and Coleman have made their position clear I mean jumping back to February and the budget was announced they said that Max Kerr would have to be within its financial budget for the year hence why you're having to make these savings and as recently last week he said that Max Kerr must operate within its given budget irrespective of the demands on the service is this measure here something of a bit of a political football for Max Kerr um do you know that this is going to be unpopular with the public and therefore make the move with almost the hope of provoking politicians into action at all because we we've already had an onk and mhk speaking out quite strongly on this absolutely it being timbled this month absolutely not and that is the disappointment that that is even a perception you know we are all professionals um the board operate um with a high degree of professional integrity I'm a clinician as are many other people on the board so this absolutely isn't used as a political football there are over 195 saving schemes running concurrently in mhk's care to help deliver those um 19 million pounds worth of savings that we need to to do we are all very careful to choose the schemes that will ultimately have the least impact and it is disappointing when that's leveled and it's disappointing when that comes from politicians i've taken the opportunity to brief politicians on this um there is a responsibility on us all to make the best decisions and to do that responsibly and to not alarm the public um and we take that role very very seriously reducing and delaying putting a potential two to three months delay in elective surgery um is one of those difficult decisions but against a risk based of all of the decisions that potentially could be made um this one is one of the least impactful as i say you know i find it really concerning that um there is a view that mhk's care would would do this as a as a political gesture to have the most impact it absolutely isn't um and and as i say we we take our responsibilities really seriously comin have made it absolutely clear to us that we have to come back into balance and um and that's why we've deliberated over a wide range of schemes we we seek the support and engagement of all of our staff in helping make some really difficult decisions for the organization um and that is what i have briefed some of those politicians on um and given the assurances so i'm very disappointed when some of that briefing has not been played back in a truly responsible way um because the context behind some of those decisions was understood um and uh and like say we will uh we will continue to monitor the impact of this as we implement it our our desire is is that actually this is for a much shorter period of time than what we had planned um but at but at the moment um you know what's in the plan is potentially up to six months um and uh but yeah we have to make those savings thank you for making it to the end of the Manxeradian newscast you are obviously someone with exquisite taste may i politely suggest you might want to subscribe to this and a wide range of Manxeradia podcasts at your favorite podcast provider so our best bits will magically appear on your smartphone thank you (gentle music) You
