Dear Editor,
E B John mused, ‘I cannot help but wonder why he (Henry Jeffrey) did not advert to his stewardship as Minister of Health’ (There was a distortion of the proposed management model for GPHC, SN: 17/01/2019). When speaking to my tenure at the Ministry of Labour, Human Services and Social security a few weeks ago (SN: 27/12/2018), I did state that I could ‘make a similar presentation for any of the ministries I led.’ However, here I will deal with the specific issue raised by E B John, for it points to an omission that is much more important than the Georgetown Public Hospital Corporation not having an independent budget, and goes to the heart of why the entire health care system has not significantly improved over the years.
I believe that the consultancy Mr John referred to was completed by Dr Kenwyn Nicholls, who, in his report of November 1997, noted that, ‘The issue of autonomy (freedom from the direct control of the MOH –Ministry of Health) at the PHG has been mooted for well over a decade; many past studies of the PHG have recommended this form of governance and management for the institution.’ I arrived at the MOH in December 1997, and in about mid-1998, we decided that the kind of autonomy identified by Nicholls was necessary if, even at our paltry level of financing, public health services were to be optimised.
This was never going to be as easy as it sounded. There was, for example, opposition from the TUC: “The Government is not privatising the Georgetown Hospital and it is committed to seeing that all citizens have access to available medical treatment regardless of their individual wealth. The TUC has penned a letter to me in which it stated that: ‘Notwithstanding press statements to the effect that the move was not intended to privatise health, the actual effects of the government’s action will be tantamount to privatisation’. I am not certain how the TUC reached this conclusion but I would welcome an explanation” (The Georgetown Hospital Reform Proposal: The Facts. MOH, 1999).
We also decided to use the Georgetown Public Hospital as a pilot of this kind of institutional divestment as it was easily accessible. Remember that my tenure was during the shortened PPP/C term, which lasted just over three years, and by the time I left the ministry in March 2001, the GPHC had been legally established as a semi-autonomous institution, and discussions were taking place with the Ministry of Finance, Public Service, NIS etc, to implement the new budgetary, personnel and associated arrangements. I have recently been reliably informed that by 2005, the hospital had its own independent budget and other administrative arrangements.
What it does appear has not happened to date is the establishment of comprehensive performance indicators, monitoring arrangements and sanctioning provisions at the institutional and ministerial levels, and these are critical if the hospital’s services are to improve and the micromanagement detected by Mr John is to cease. I have a good relationship with Dr George Norton, so when the coalition came to office and he became Minister of Public Health, I provided him with some public advice (SN: 24/6/2015).
I advised that setting up autonomous boards and health Regions is ‘counter to the commonplace notion that management requires as detailed as possible oversight of the managers’ obligations. …How can one justifiably hold a manager accountable if the minister consistently intervenes and directs the day-to-day operations of the organisation?’ I suggested that, ‘In a large established institution such as the Georgetown Public Hospital, after properly benchmarking the level of the present services, hundreds of indicators and sub-indicators will have to be created and effectively monitored by the administration and periodically by the subject ministry.’
I reminded him that, ‘Partly to help to benchmark the services the hospital was providing…in 2000 the ministry completed the first – and I believe last – public hospital inspection under the chairmanship of Dr Vibert Shury …. The Shury inspections sought to be comprehensive, touching upon some seventy services. In many ways, the report was quite scathing, the media picked up on it and elements in the political establishment, rather than seeing it as something that should be periodically done to help improve care delivery, thought that it played too much to opposition propaganda. The inspection of private hospitals is institutionalised in the ministry but the public hospital was thought immune from such inspections even though a semi-independent board was being put in place!’
In conclusion I suggested to Dr Norton that, ‘The health system requires major reforms and I believe that the minister should eschew short term fixes and the pressure towards micromanagement. He should seek to put in place arrangements that will allow management to be creative and to set and monitor targets based upon performance incentives and sanctions. In itself, whatever system he chooses, this would be a formidable enterprise that will only become embedded if followed persistently over many years.’ So far as I am aware, nothing like this has been done and the historic micromanagement continues.
Mr John, I hope I have allayed some of your concerns.
Yours faithfully,
Henry B Jeffrey
