It is time for Jersey to accept global best practice and make major reforms to Health’s structure, the professor behind an £85,000 report alleging a ‘Jersey Way’ within the hospital has said.
Based on more than 70 interviews with 53 staff, senior clinical lecturer Hugo Mascie-Taylor’s report claims that bullying, a “bias against standardisation” and “vested interests” are dominant in the health service.
Poor processes and understanding of roles are also reported, in addition to an apparent lack of accountability for senior staff – some of whom were said to enjoy "undue influence".
The report also spoke of a tendency to "over-rely individual competence, personal autonomy and goodwill' to ensure patients are kept safe" and a culture of the "heroic individual rather than the effective team" in Jersey, which he said he had not "encountered anywhere else in the world".
Together, these issues could put patients at risk, Professor Mascie-Taylor concluded.
He said that the Director General and hospital management had been unable to effectively tackle them due to having incorrect "architecture" around them and staff's apparent "unwillingness" to change.
Many of the problems within the Health service, he said, were the result of an "unwillingness" to change, and incorrect "architecture" preventing the Director General and management from making changes.
The report, whose findings echo several released within the past three years, puts forward 61 recommendations for improvement – the most significant of which being the creation of an independent review board drive healthcare reform. All of these have been accepted by Health.
Express spoke to Professor Mascie-Taylor about how the report came to be, its findings and recommendations..
Professor Mascie-Taylor said he was approached by the Director General Caroline Landon, who had been "urged on" by Medical Director Patrick Armstrong and Chief Nurse Rose Naylor, to conduct his review of clinical governance.
He had previously been External Assessor during the appointment of Medical Director Patrick Armstrong, and was asked by Ms Landon to mentor him in the role, which involved weekly meetings with Mr Armstrong.
Last year, Ms Landon formally approached Professor Mascie-Taylor – who explained that he had carried out similar reviews in Western Australia and the Middle East – about assessing Jersey's service.
"I thought was actually quite a courageous thing for her to ask, because to invite someone in, essentially to critique your organisation, is quite a brave thing to do really," he said.
Mr Mascie-Taylor's report was based on comments made in interviews with dozens of health staff, which he gathered during trips to and from the island over the course of 18 months.
He said that he had not opted to conduct a data-driven review due to a lack of consistent data being collected by the department.
"...It's actually quite hard to look at what outcomes are being achieved, either by the organisation or by individual departments, or even more individual consultants... so looking at the outcomes, which is what one would like to do, wasn't possible, and indeed it's one of the weaknesses that needs to be remedied," he explained.
Giving an example of the data he would have expected to see, he said: "...In intensive care there's a group called ICNARC [Intensive Care National Audit and Research Centre] who look at the outcomes of intensive care units across the UK, so it's perfectly possible to benchmark your unit against all other units. In many of the procedure-based specialties, in surgery, there are mortality rates, morbidity rates, consultant-by-consultant."
"It's not a consistent picture," he later added, "but what happens in most countries, of which I'm aware, is that that information, aggregated up in some form, and available to be interrogated if necessary, would go to the board of the organisation, and through the board of the organisation it would be placed in the public domain, so that you might get to go to a board meeting once a month and listen to all of this... The important point is that it has to be gathered, it has to be looked at, it has to be evaluated against other organisations and other people, it has to be shown to a board that look at it, and it has to be put in the public domain, and all of that improves quality."
While the evidence will naturally be subjective, Professor Mascie-Taylor argued there was still value in an interview based review.
"...One of the most telling tests about a hospital is its staff survey, so if you ask staff the simple question 'would you like to be treated, or would you like your relatives or friends to be treated in this hospital?', if the majority of them say 'no' then you've got to start worrying."
He further noted: "the essence of it is, clearly if you talk to one or two people you're pretty vulnerable, but if you talk to the number I talked to - 70 odd - and then you report only consistent themes, then you have reached a point where a lot of people believe this to be the case, so if you like it's triangulated, in a academic sense you'd say you're triangulating the information by checking it out with others.
"Now, of course, you could check it out with 20 people and they could all be lying, so there is in a way no end to that argument but I didn't put anything in it that had not been verified but at least one, if it was a specific point, or often by quite a large number of people, so the themes of it were, had you and I done it together I think well before we got to 77, or however many it was, you would have observed that there are consistent themes here. So I don't contend that that's the absolute truth, but it's a pretty reasonable indicator of what the staff think about the organisation they work in."
One of the areas of concern highlighted by Professor Mascie-Taylor was an apparent disparity in how public versus private patients are treated. The report said private patients were more likely to benefit from consultant-level treatment.
He said, however, that this was not based on figures – only "what I'm told".
He added: "The whole report, if you like, is in that sense anecdotal. If you wanted to know that you'd have to do quite a difficult, not an impossible, you could do an audit on it all... I wouldn't actually be well equipped to do that audit, and it would be highly time-consuming and expensive, and in my view, not really worth it because you know enough to know that the issues need to be resolved. You don't need an awful lot of information to say that there is potentially a problem here."
While the report makes serious claims about staff behaviour, it does not single out specific individuals or departments.
Professor Mascie-Taylor said he believed that it was a "minority that are bad apples."
"I don't how big a minority, but a minority, and then probably they're only bad apples in one particular way. So I think it would be quite wrong to be overly alarmist about this. I don't think the staff in that institution are particularly different from that in any other hospital, I think it would be wrong to conclude that, I just think that the way it's constructed, with a lack of accountability, and a lack of openness and transparency, means that you're not quite sure what is going on. So it's more about a lack of assurance, than about there's definitely a problem. It turns it on its head, and if you said 'was I sure that it was unsafe?' I'd say 'no'. Am I sure it is safe? No."
Asked if he could be any more specific about the areas of particular concern, he highlighted theatres – an area that was the subject of a damning internal review, which was leaked to Express and reported on earlier this year - and "occasionally on some wards".
"I didn't pursue which wards," he admitted, "because I wasn't doing that sort of investigation, I was doing a much more high-level picture of the organisation than a detailed investigation into either departments, or certainly not into individuals, so that would be inappropriate."
The report notes that some interviewees spoke of a 'Jersey Way' - a phrase hinting at corruption, malfeasance and vested interests popularised during the Haut de la Garenne investigation and later in the Independent Jersey Care Inquiry – within Health.
Asked to explain what this meant in the hospital context, Professor Mascie-Taylor said: "I'd never heard this expression, 'the Jersey Way', until I came to Jersey, and it seems to be about a lack of openness, lack of transparency, decisions perhaps being made behind closed doors, a degree of complacency, that 'the way we are here is fine, and please leave us alone'. 'The Jersey Way', is not, as far as I know, defined in the dictionary, but it's remarkable how often it's said."
While he quotes the phrase, the "fish rots from the head" in his report, the Professor is clear that structural and cultural rather than leadership difficulties are to blame.
Firstly, he says the Government must "make some very clear policy decisions" with the Minister accountable for their enactment, while Health management should aim to be more "assertive in the way that they deal with bad behaviour, assertive with, if you like, a reluctance to modernise, and hope, when they are being assertive, they're supported by the government and the people of Jersey, because if they're not, they will fail, and whoever succeeds them, will also fail."
"So if you go back and look at reports previous to mine - certainly, I've gone back as far as 2006, and the messages are consistent. So you can replace the senior management of the organisation as many times as you like, but if the environment in which they are working isn't appropriate, or isn't supportive, then they will fail, whoever follows them will fail," he added.
The solution he puts forward, therefore, is a board-driven structure as featured in the UK and other jurisdictions.
While it has been argued by many that the different structure of Jersey's health system requires its own bespoke structure, rather than what some have termed 'NHS-ification', Professor Mascie-Taylor believes that this is not the case – and that it is time to leave this view behind.
"It's what happens in the rest of the world. So there's been probably for 30 years now, an academic focus on quality and safety, and a whole movement, if you like, both academic and within organisations, on how you drive safety and quality. And that's not a UK movement, it's a worldwide movement. And it's all set out in the academic literature, in the practice of endless practitioners, so there's not secret about any of that, it's all well-known.
"But Jersey hasn't done what other countries have done in this respect and to some extent, what I'm saying is Jersey just needs to catch up."
He continued: "So let's take an example: I don't know of another hospital of the size of Jersey, or another healthcare organisation the size of HCS, that doesn't have a board with independent non-execs. Anywhere in the world, I don't know of one, until I came to Jersey! So I suppose my question would be 'how much evidence does Jersey want?' before it says 'actually, everyone around the world has accepted this, why don't we?'. Because if they don't accept the current proof, I don't know what they would accept really. It is one of the interesting things about Jersey, there's a sort of acceptance that 'well, we're different' as if that were therefore a good thing. It's quite fascinating."
He added: "There is this of sort sense one has there that Jersey is somehow special, and in many ways, it is a delightful place, isn't it? A lovely place to live I would think. I really like coming there, and I would hope to come back.
"But, there is, at least amongst some, a sort of sense that because we're an island, we almost should be different. Ultimately, that's a choice for the people of Jersey, it's not a choice for me. So my job is to say 'well, if you want to be as safe as possible, this is what I suggest you do, because everybody else does it. If you, the good people of Jersey, don't want to do that, that's absolutely your choice, it's not for me to tell you'.
"Just as when I'm in the Middle East, it's not for me to say 'you should treat public and private patients in the same way'. It's their country, they have a choice. So the people of Jersey have a choice, and it's up to government to articulate what that choice is. At least be clear about it. So for you, as a citizen of Jersey, what you're getting for your money."
Professor Mascie-Taylor said it would be "most unfortunate" if his recommendations were seen to be about the NHS or UK.
"What I am basing my recommendations on is certainly not the NHS, it's based on... a perspective of the English-speaking world. So, it could have been based on Western Australia. It certainly could be based on the United States...This absolutely not to do with the NHS or the UK.
"The corporate governance - this is how organisations, of all shapes and sizes, all around the world, all work, except this one. So either they're wrong. Do you see my point?"
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