Sometimes the 'Guernsey way' is right

LAST week's States meeting was a busy one – so much so that deputies had to start early and work until seven o'clock at night.

On the agenda were population controls, maternity leave and yet another debate on funding the transport strategy. But the item which grabbed my attention most was the £3m. increase in HSSD's budget. Perhaps not surprising, given my background.

The ensuing debate was certainly passionate, with some stark polarisation. In some ways I sympathised with comments from those on all sides, even though they had nothing obvious in common. Let me highlight a couple of such differing contributions.

Former HSSD minister Deputy Hunter Adam was first in with all guns blazing. He made a robust defence of the quality of care provided at the PEH – including the maternity service – pointing out that the statistics revealed low levels of mortality and other serious problems.

He went on to defend the concept of 'the Guernsey way' and implied that recent external reviewers simply hadn't understood the island's unique situation, with no junior doctors and an all-consultant medical service relying heavily on the input of highly skilled and experienced nurses. He also pointed out that previous external reviews of our hospital – including maternity – had been positive.

Deputy Adam seemed frustrated – angry even – that the new HSSD board had meekly accepted every criticism in the NMC review without any apparent pushback, saying that that response had destroyed staff morale. He criticised the very expensive HSSD response to that report, which will cost the taxpayer millions.

By contrast, Deputy Fallaize warned against complacency. He claimed it would be irresponsible to ignore the clear advice of outside experts. Instead he laid the blame for any shortcomings squarely at the door of the vicious squeeze on HSSD's budget over the last five years.

There is much to be said for both positions.

There's no doubt that the year-on-year, real-terms reduction in HSSD's budget has been like watching a flawed pressure cooker waiting to explode. Or watching a film where you know there'll be a sad ending but not knowing exactly what form that pathos will take. Where will the cracks show first?

But that doesn't mean that just throwing cash at our health service will cure all its ills. Given Guernsey's current financial constraints, there's obviously a limit to the amount of extra cash the island can spend on health and social care. Any budget uplift can only be spent once, so it's vital that HSSD gets the biggest bang it possibly can for its buck. Spending a big chunk of any available extra cash in ways that don't deliver the optimum cost/benefit ratio would be a disaster.

There's more than a smidgeon of suspicion that in their desire to comply 100% with proposals from external reviewers, the current HSSD may be doing just that. So keen are they not to be seen as 'in denial' over the flaws highlighted in the maternity service that they may be overreacting in a very expensive way.

In some ways that's much better than under-reacting, but the stark fact remains that cash thrown at one part of our health service is cash that can't be spent elsewhere.

For example, it is obviously a Rolls-Royce provision to have a consultant obstetrician in attendance at the maternity ward 24/7. But will such a costly initiative improve the safety and quality of the service as much as the same sum spent on other aspects of HSSD's mandate? I doubt it. It has to be remembered that professional bodies always advocate for the ideal provision within their own area of expertise. But if HSSD develops a habit of going along with every suggestion in every external review, then Guernsey will soon be bankrupt.

What about this argument over 'the Guernsey way'?

I completely agree with Deputy Adam that such a concept is valid and shouldn't be completely rubbished.

At the time of the NMC report, the chief officer of HSSD was making it clear to all within the corridors of power at the PEH that this was an expression she never wanted to hear used.

She even warned board members against using it.

I think that was a gross overreaction. Arrogant even, showing disrespect for some very good practice that is tailored to Guernsey's unique position. What's needed is some balance.

On the one hand, there's clearly a danger that the concept of 'the Guernsey way' can be used as an easy and convenient excuse for sloppy practice and failing to comply with best standards.

Such complacency would be dangerous.

On the other hand, we are in a very different situation to the UK.

Not only do we have a unique, consultant-only system of secondary care with no junior doctors, but the PEH also has to provide a range of treatments and procedures that no hospital serving such a tiny population would ever provide in the UK.

Unless we want to see that change completely, with islanders having to go to tertiary centres in England for many more treatments and procedures, then we simply have to do things slightly differently to the NHS.

I'm sure the people of Guernsey don't want the PEH reduced to the level of a cottage hospital or to have to travel off-island more frequently for treatment. Nor could we afford it.

On the other hand, neither can we afford to run the PEH in exactly the same way as a hospital serving a population of a million in England.

The diseconomies of scale simply don't allow it.

So how to square this circle?

The only answer is to do things slightly differently, even if outside reviewers sometimes look askance. In other words, 'the Guernsey way'. And that means having the guts to sometimes argue back and justify not being identical to the NHS.

We are not just talking about maternity here.

The philosophical question of whether Guernsey should slavishly mirror the NHS has implications for our whole health service.

Nor would the impact of trying to do so increase only the budget of HSSD. As the Social Security minister rightly highlighted, any attempt to tick every NHS governance box will have huge and costly implications for the States' insurance fund too.

It's a fine line. Stubborn refusal to change and take expert advice could be dangerous and short-sighted.

On the other hand, running to Treasury and Resources for budget uplifts to comply with every single external suggestion may be a good way to avoid criticism, but it's unsustainable.

More than that, it will distort HSSD's priorities for what will always be a finite budget.

We need to be humble enough to listen and learn but at the same time self-confident enough to dare to be different. After all, we've been different for decades, yet, despite being a big defender of the NHS, I think our standard of care is far superior.

Or certainly used to be.

If the new regime – both officers and politicians – think the best way forward is to be a pale shadow of the UK health service, then they are plain wrong.