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IN-DEPTH: “How much evidence does Jersey’s health service want?”

IN-DEPTH: “How much evidence does Jersey’s health service want?”

Friday 26 August 2022

IN-DEPTH: “How much evidence does Jersey’s health service want?”

Friday 26 August 2022

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..

The origins of the report

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.

A lack of data

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."

Anecdotal evidence

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."

A "bad apple" minority

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 'Jersey Way'?

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."

At the top

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.

"Jersey just needs to catch up"

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?"

Click HERE to read the full report.


Q&A: How will the Government act on the Mascie-Taylor report?

FOCUS: Another review identifying more failings in Health

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Comments on this story express the views of the commentator only, not Bailiwick Publishing. We are unable to guarantee the accuracy of any of those comments.

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Posted by Lesley Ricketts on
So what has the Director General been doing since she arrived to take charge?
Posted by Tobias Philpott on
So the following is admitted by Professor Mascie-Taylor himself
1. He has based the report entirely on anecdotal evidence. He has spoken to 70 out of 1,500 staff.
Who selected the staff, he spoke to?

2.He is another of the coterie of "consultants" engaged at huge expense and with absolutely no governance in their recruitment or accountability for their action or in most cases, inaction.

3. He is a mentor to Dr Armstrong, whom himself has been the subject of controversy in how the Disciplinary processes were distorted and in a letter from Senior Consultants, subsequently leaked to the press, he and senior management were particularly mentioned.

4. No acknowledgement of the challenges faced by Hospital Staff in implementing high quality healthcare, with staff shortages and staff resigning because of toxic culture that persists on this senior management's watch.

This is a stich up and ruse to divert attention away from the failings of Senior Managers and instead blame the staff
Posted by Tobias Philpott on
Also need to consider the statement that "Jersey needs to catch up".
With what?
The shambles that is the UK NHS and which the Professor and others like him have turned into a beurocratic nightmare. 1000s of Managers and committees to wade through to get anything done.
I have relitives in the UK and they envy the level of GP care and hospital care we get here. Not perfect but a way lot better than the UK which the professor wants us to turn into. The NHS is bad because of bad managers and staff and people in Jersey won't accept the NHS management clones, no matter how many "reports" are created. What a laugh that this is even being called a report, when the professor has had no oversight and just self selected who he has "talked to"
Posted by Keith Marsh on
So now we have a further report, requested by Director General Caroline Landon, to tell us, what we knew that the hospital is FAILING.
Everyone knows if you are trying to see a Consultant, because your G.P. feels there is an urgent need to get specialist help ~ eventually you get a date, which will be changed a few days/weeks later, and changed yet again. Sometimes these bumps are MONTHS longer.
Meanwhile, your GP who referred you is helpless, and you the individual does NOT get treated.
Things MUST CHANGE and if the DG can't do it, she MUST RESIGN.
Posted by Esporta Johnson on
It seems to be a courageous move by top leadership of HCS to voluntarily ask for an external review right before elections. What is less clear is how the author was selected. Was there an open tender to procure the review, was CQC ever invited to get involved? The previous freelance consultant had also been hand-picked and after spending half a million we don’t seem to benefit much from her reviews. Most of the sixty recommendations in the latest report are well known and quite universal. We know that we don’t have proper performance metrics in place. We know that in most geographies privately insured patients get better access and often superior conditions of care. The professor interviewed 29 leaders, chiefs and managers as well as 22 consultants - yet stopped short of explaining how these consultants were selected. Not sure if any of the consultants who left the hospital recently were interviewed. No front-line, non-managerial nurses seemed to be contributing. The report then portrays the leaders as hard working heroism but failing due to poor ,architecture’ and the stubborn employees resisting change. It does not question leadership’s competences. It seems to detract attention from the critical issue of poor leadership. It raises concerns about patients with private insurance getting better access to care. Not a single recommendation addresses the big elephant of widespread bullying, intimidation and fear based management style. Nothing will change and we will commission another review by a consultant hand-picked by director general then.
Posted by Esporta Johnson on
77 interviews with 53 people (?) of those majority being directors, chiefs and managers (29) plus a minority of consultants (22), likely selected by the leaders, no front line, non-managerial nurses, no health care assistants mentioned. No surprise that the picture painted is that of hard working managers and chiefs struggling with employees resisting change, forced to work in the wrong architecture. The author was selected by director general, no clarity if the review was proposed to independent organisations like CQC. No mention of the results of organisation-wide survey ‘Be Heard’. The recommendations are quite obvious and universal. The report attempts to divert attention from the key issue of incompetence of top leadership and the quality of people they surrounded themselves with. The leaders had years to act, to change the architecture, to change the culture. They enjoyed and reinforced it. 100 recommendations won’t help if the same people, not trusted by their teams continue leading HCS. The fish rots from the head.
Posted by Paul Troalic on
Well this is pretty damming. Where I disagree with him though is when he talks about changes in management bot being answer. Problems always start at the top because either they are wrongly appointed, are not correctly told what is expected of them or they are just incompetent!
Clearly no one is carrying out proper appraisals of te senior staff.
Unfortunately it is the patients that suffer.
What is appalling is the suggestion that private patients are treated better than non paying patients. This is completely wrong and must be changed immediately.
If the culture is wrong the service will suffer. Someone needs to grab this situation and bring about gradual change.
Sadly some people should not be in patient care and this should be identified at interview. Qualifications may be secondary.
Posted by Scott Mills on
When the system is broke, simply buy & Build a new container (new hospital), because that'll improve and sort out all the issues. Similar to moving seat on the titanic.
Posted by Esporta Johnson on
The report is indeed ‘anecdotal’. Most of the anecdotes seem to come from the management - 29 out of 53 interviewed individuals represented management. For a more balanced picture one may look at the results of ‘Be Heard’ survey, you can google ‘The sickness in the Health Department’ Bailiwick Express Monday 06 September 2021. Quite recent. Hundreds of HCS employees participated, the picture is quite different from the one in the recent, sponsored anecdotal review.
Posted by Nikos Makrigialos on
It is naive to believe that there will be any personal changes at the top. Jersey is a small world - consider how eagerly the review was accepted by the new Health Minister. It is all a performance to demonstrate greater and greater scrutiny, to reassure the islanders. The fish rots from the head. Look if anything changes, if the director general and her team will truly be held accountable for the mess in health department. And then ask yourself 'where is the head'?
Posted by Stathia Ekdikisi on
The report addressed the areas that the Director General wanted to be addressed. It skilfully bypassed the elephant in the hospital. It is a typical red herring report. I especially like the populistic/socialist element intended to increase buy-in from the public. Several recommendations refer to patients with private insurance or those willing to pay extra on top of the public taxes they pay like everyone else. The review steers the opinion of readers to believe that all patients should be treated the same way. It is a catchy idea for all those 12 thousand patients on the waiting lists and to their relatives. Rather than asking why we have 12 thousand patients waiting, following relatively mild experience of Covid pandemic - the author skilfully challenges the fact that those paying extra get seen quicker or get better conditions overall. I know health systems of many countries and do not know a single one where private insurance does not offer advantages over free public care. It certainly does offer benefits in the UK. Why would anyone go private then? Today website 'Jersey Private Patients' makes an explicit promise 'so get better sooner and enjoy the comfort of private hospital care'. It further explains 'Why go private: quick access to treatment, flexibility when you have your treatment, choice of consultant and en-suite room'. It further mentions access to treatments that may not be available in public. It is the same in the best healthcare systems. And if in our wisdom we decide that in Jersey private patients have to wait as long as the 12.000 public patients do, that they can get only the same standard implants as the public ones, stay in the same type of rooms etc. - what will happen then? The today's privileged private patients operated in the evenings or on Saturdays will join the public waiting list. The consultants for whom private practice was one of the factors convincing them to move families to Jersey will go elsewhere and we will get more locum doctors. The Jersey job adverts for new consultants do mention ample opportunities for private practice. Of course everyone agree that treatment of private patients should not happen at the expense of the access for public patients - but this is a different story and we have regulations in place to ensure it. Don't get distracted with the populist/socialist ideas. Ask the right questions to find who is responsible for the failings of our publicly funded healthcare. And what it means for those responsible to be held accountable.
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