21 September, 2023

Mr. Speaker,

I rise today to provide this House and the public with an update on the work undertaken, and progress made to date, to strengthen Bermuda’s health system.

Bermuda’s health system needs strengthening to ensure all residents can access affordable and essential healthcare services that are delivered effectively and efficiently. The results will include improved patient experiences and health outcomes, and a decreased economic burden overall.

Mr. Speaker,

The Bermuda Health Strategy 2022-2027 supports the core vision of “healthy people in healthy communities” and sets out eight strategic principles that are intended to set us on a new path towards an equitable, accessible, and sustainable health system for the Island.

These principles are:

1. promoting healthy living and preventative care,
2. focusing on person-centred care,
3. understanding our population’s health needs,
4. providing access to healthcare coverage,
5. strengthening our healthcare workforce,
6. harnessing healthcare technology,
7. partnership and collaborative working, and
8. preventing wasteful care and promoting efficiency.

Mr. Speaker,

Achieving a stronger, more sustainable health system requires us to progress all eight strategic principles – and I am pleased today to report on the progress made to date.

First, Principle 1 - promoting healthy living and preventative care… We know that health promotion and disease prevention are essential ingredients in building a more robust health system and a healthier

population. Many of the chronic illnesses impacting our community and placing a heavy burden on our healthcare resources are strongly related to lifestyle factors such as poor diet, physical inactivity, and smoking.

We understand that more must be done to empower and support people to lead healthy lifestyles, and we will do that.

It is important to note that the emphasis on health promotion includes mental health as well. There is a recognised need to challenge historical stigma and preconceptions about mental health. Good physical and mental health are collectively a part of our efforts to promote wellness and healthier living.

For 2023/24, the Department of Health’s Health Promotion Unit received additional funding for implementing the HEARTS programme, new health promotion and wellness initiatives, and facilitation of Mental Health First Aid training. This is just a start.

Mr. Speaker,

The second and seventh strategic principles of focusing on person- centred care and partnerships and collaborative working are encapsulated in work undertaken by the Bermuda Hospitals Board (BHB), Bermuda Cancer and Health Centre, and now, the Ministry of Health, to develop integrated care pathways that map the journey of patients and service providers along different healthcare tracks.

Integrated care pathways set out in detail the essential care steps for people with specific needs from the viewpoints of the patient and their families, and the care provider. The care journey is mapped from beginning to end. It defines what happens, when, and who is responsible at any stage along that journey.

The BHB has developed care pathways for Breast Cancer, Prostate Cancer, and End of Life care, working with Bermuda Cancer and Health Centre and others. The Ministry engaged KPMG to work with patients and care providers to develop integrated care pathways for the First 1,000 Days of Life, Chronic Kidney Disease, and Acute Adult Mental Health.

Approximately 1,135 stakeholders were directly engaged within these three care pathway initiatives. This included 751 residents who responded to the three community surveys and approximately 255 patients, health service providers, and other health stakeholders who participated in workshops and one-on-one interviews.

This is an excellent example of the level of collaboration and diversity of stakeholder voices we are seeking to include as we continue the work of generating solutions to strengthen Bermuda’s health system.

Mr. Speaker,

The purpose of collaboratively developing these care pathways, and in particular, including both patients and service providers in the exercise, is to identify gaps and/or fragmentation in care and seize opportunities to improve coordination of, and reduce duplication in services. In this regard, having a person-focused approach is critical to capturing all elements of the care journey.

The patient’s care journey provides the patient and family viewpoints, while the service map reflects what each clinician does.

These two elements of the care journey together, inform the solutions for an integrated care pathway result.

With this, more comprehensive information available, healthcare providers can implement changes in the care journey that improve the experience of the individual receiving care and, most importantly, improve health outcomes.

The integrated care pathway for Acute Adult Mental Health has been completed, while the final drafts of the First 1,000 Days of Life and Chronic Kidney Disease are the subject of final reviews.

Mr. Speaker,

We have also made progress in Principle 3 - understanding our population’s health needs…another strategic principle.

Last year I reported to this House that the Ministry would undertake an assessment of our population’s health needs. To better manage health system strengthening, given the Island’s financial constraints, we need to understand our priority health needs to properly align our efforts to sustainably improve the health of the people of Bermuda.

Mr. Speaker,

I am pleased to inform you that, with the support of a Public Health Registrar with the UK Health Security Agency and UK Overseas

Territories Team at the Department of Health and Social Care in London, along with resources kindly provided by the Department of Statistics, public health professionals, epidemiologists, health promotion professionals, and representatives from the Bermuda Health Council, Bermuda’s first Joint Strategic Needs Assessment or JSNA is complete and has served to provide this strategically critical baseline of information.

Analysing the best data currently available, the JSNA sought to understand the health needs of Bermuda by considering:

• Bermuda’s population profile and the social determinants of health,
• our health behaviour and risk factors,
• the causes of ill health and death,
• the specialised needs of vulnerable groups (including children, the elderly, and people with disabilities), and,
• the current state of our healthcare services.

It is a foundational piece of work that brings together the many factors impacting our health, healthcare, and health system in one document.

Mr. Speaker,

Honourable Members will know it is not just medical care that influences our health. Social and economic conditions, including our work, housing, education, and local community networks, are important factors that define our health. These are the factors known as the social determinants of health.

By undertaking this comprehensive Needs Assessment using the concept of the social determinants of health – which is a more “holistic approach” – the Joint Strategic Needs Assessment is a report that can be used by the whole of government and civil society to develop actions to protect and promote health in various settings, whether in the classroom, the workplace, or local community settings (i.e., where people live and recreate). The JSNA will be available for download on www.healthstrategy.bm.

Mr. Speaker,

Some of the JSNA recommendations include:

• developing strong and linked health information at an individual level;
• developing a model of health and social care focused on care of the elderly;
• focusing on the social determinants of health, rather than just healthcare;
• developing payment mechanisms for clinicians involved in healthcare quality improvement and health system strengthening where improvement in outcomes can be demonstrated;
• improving the quality of domestic incident reporting systems; and,
• incentivising the provision of smoking prevention and cessation services.

There are 24 recommendations in total, a number of which are beyond the remit of the Ministry of Health, and several of which are being worked on by different Government departments and agencies already.

The decision to enlarge the assessment to include the social determinants of health contributed to recommendations that are wide- ranging, and are also reflective of the extensive needs of the population.

The Ministry intends to undertake another Joint Strategic Needs Assessment in five years.

Mr Speaker,

Strategic Principle #6 is harnessing healthcare technology.

On this point, Honourable Members will recall the Government’s commitment to developing a National Digital Health Strategy.

I can inform this House that the final draft of the National Digital Health Strategy is also largely complete. In undertaking the exercise of developing the National Digital Health Strategy, an interdisciplinary working group of health and technology professionals from the public and private sectors was set up in October 2022. Their work resulted in the development of 15 strategic recommendations that lay out a holistic approach to implementing a national digital health system in Bermuda.

Digital health is defined as embracing “the integration of technology, people, and systems to organise and deliver healthcare services and data effectively”. The Strategy outlines a best practice approach to ensuring digital health can become a reality and that members of our community can benefit from the enhanced care that is possible through this level of integration.

This would include:

• residents having online access to their health records through patient portals.
• practitioners being able to better coordinate care with more immediate access to test results and the input of other professionals on the treatment team; and
• a reduction of duplicative lab tests and scans, thus reducing waste and inefficiency.

Ultimately, the National Digital Health Strategy seeks to integrate efficiency and cost-effectiveness into the healthcare system, while tackling the current burden of health expenses and the fragmented nature of healthcare delivery in Bermuda. And, yes, it is intended to support the delivery of universal health coverage.

This is a multi-year effort, and I look forward to sharing the full report in the coming weeks.

Mr. Speaker,

With the Joint Strategic Needs Assessment and National Digital Health Strategy completed, the Ministry has established Bermuda’s baseline for health system metrics.

The purpose is to provide a set of metrics that will enhance our understanding of health system outcomes. These metrics will inform decision-making as we seek to improve healthcare delivery at a national level.

A core working group of key stakeholders in public health and the private sector reviewed existing health system metrics available for inclusion as a starting point. The process has brought together in one place, health system information from a variety of data sets.

Selected health system metrics include health expenditure per capita, out-of-pocket health expenditure, life expectancy at birth, infant mortality rate, number of nurses (by population), average length of hospital stay, avoidable mortality, and emergency department visits based on the severity and intensity of patient care episodes.

Mr. Speaker,

This first set of baseline health system metrics contains the metrics that are available in the short term. A ‘Task and Finish’ group will identify and prioritise future key metrics. Moving forward, as the National Digital Health Strategy is implemented and impacts the secure collection of health data, additional health metrics can become available and be collected more efficiently. Presently, the Ministry is working to create a public dashboard to display the baseline health system metrics that are already collected.

Mr. Speaker,

An additional project embarked upon this year is the Merger of Government Funds. This is linked to strategic Principle #8 - preventing wasteful care and promoting efficiency. As stated in the Bermuda Health Strategy 2022 - 2027, the health need is for the Government to realise opportunities to ensure the future sustainability of healthcare in Bermuda. This includes assessing the sources and uses of all the

Government’s health funds. The Ministry is currently reviewing the options for optimisation, recognising that reform of overall health system financing is the larger project.

Mr. Speaker,

As Honourable Members can see, the Bermuda Health Strategy 2022- 2027 is not a document that is sitting on a shelf gathering dust. The strategic principles contained within it guide the work of the Ministry and collectively following through with them, puts us on the path to strengthening our health system.

The one strategic principle yet to be advanced is Principle #5 - strengthening our healthcare workforce. This will be included in upcoming projects.

While all the strategic principles are important, Principle #4 - providing access to healthcare coverage – in other words, universal health coverage – remains a fundamental principle that I would like to turn to now as part of this comprehensive update. As I do so, you will see that the strategic principles, while listed separately in the Health Strategy, do overlap in their contributions to health system improvement.

Mr. Speaker,

The Ministry of Health has spent the past year completing the setup of the transitional governance structure needed to develop and manage the implementation of universal health coverage.

The Vision of universal health coverage – or UHC – is to ensure all Bermuda residents have equitable access to quality care, without suffering financial hardship when paying for these services and critical medicines.

As previously reported, the UHC governance structure includes the UHC Steering Committee, chaired by the Chief Strategy Officer reporting to me as Minister of Health. It is important to note that the UHC Steering Committee has been fully engaged and at work for the past two years.

In addition to the UHC Steering Committee, five Health Forums also comprise the UHC governance structure. The Health Forums represent the many stakeholders involved in the health system, including:

• patients,
• providers – which includes a range of health businesses such as physicians, nurses, labs, physiotherapists, pharmacies, and others,
• payors (e.g., employers),
• regulators, and
• community organisations such as non-profits and unions.

The role of the Forums is to provide insights, feedback, and recommendations to the UHC Steering Committee from their various areas of expertise and/or experiences. The Ministry of Health’s Programme Management Office executes UHC projects and supports the Forums and UHC Steering Committee.

Mr. Speaker,

The first of the Forums, the Clinical Senate, has been meeting monthly since January. The Clinical Senate is comprised of a multidisciplinary group of over 50 health service providers who provide professional clinical advice and recommendations to the Ministry of Health for its further consideration and decision-making for the Universal Health Coverage Programme.

For the remainder of the Forums – Health Financing, Health Insurers, Health Advocacy, and Service Providers – a wide range of health system stakeholders have been invited to participate, and meetings will begin next month. I want to take this opportunity to thank the Chairs and Deputy Chairs of the various Health Forums for their work so far – and the work to come! Their experience and contributions will be invaluable for strengthening Bermuda’s health system.

Mr Speaker,

The setting up of the Programme Management Office is moving forward as well. In addition to project managers who previously consulted with the Ministry of Health, three new Temporary Additional posts were approved: one for the UHC Programme Director and two for additional Project Managers.

Mr. Speaker,

The Ministry of Health is well aware of the public’s desire to know “What’s next? and When will UHC be a reality?”

Mr Speaker,

As work on the initial projects that I’ve just shared has ended, the UHC Steering Committee, with the support of the Programme Management Office, looked ahead to the next steps on the journey to universal health coverage for all residents.

Mr Speaker,

The recommendations arising from the first set of projects gave birth to a list of approximately 64 new projects, many of which carry on from these initial projects and initiatives. The next phase of work is grouped into eight health initiatives or major projects:

• Healthcare Modelling,
• National Digital Health Strategy Implementation Planning
• National Health System Metrics,
• National Health System Standards,
• UHC Core Health Services,
• The implementation of completed Integrated Care Pathways and the beginning of the process for new Care Pathways,
• Health Regulations, and,
• Healthcare Workforce Strategy.

You will note the inclusion of initiatives such as the National Digital Health Strategy, Integrated Care Pathways, and others previously reported on. The inclusion of such initiatives represents the second phase of work coming out of the initial findings and recommendations of the first phase of work.

Mr Speaker,

Healthcare modelling involves understanding Bermuda’s current and future healthcare costs, service, and population needs, including future utilisation of care services on and off the island. Healthcare modelling also includes developing options for more effective health system financing based on current and projected needs.

Phase II of the National Digital Health Strategy initiative will entail setting up an appropriate governance structure and developing an implementation plan to begin to integrate data across the health sector into a centralised system, make patient-level health data more available, and enable better reporting across the health system.

This should ultimately improve the overall quality of care and health outcomes of patients.

The national health system metrics project will continue with identifying the metrics needed for the UHC Programme, as well as the measures most needed or desired by the community.

National health system standards will involve determining the relevant data standards for Bermuda and developing an implementation plan for those health data standards. This is linked to the need to improve the coding of healthcare services and procedures in health records. The data we can retrieve from health records is only as good as the data that was input.

Both health system metrics and health system standards are part of the larger National Digital Health Strategy.

UHC core health services refers to developing the list of core health services that should be part of the UHC core benefits package.

An essential part of the assessment of the core health services centres on the learnings that come out of the integrated care pathways.

The next phase of work will comprise implementation plans based on the recommendations from the completed pathways and undertaking new care pathways.

Health regulations are identified as a project as they will be the subject of ongoing updates on an as-needed basis.

Finally, Mr. Speaker,

Developing a healthcare workforce strategy is extremely important, particularly with the intense competition for healthcare professionals and the lack of health caregivers across the health system. Our population is aging, which brings with it particular care needs that must be taken into account. Overall, having a strong healthcare workforce is essential for delivering on our commitment to strengthening our health system.

Mr. Speaker,

The Ministry and UHC Steering Committee are of the view that, if sufficient resources are in place – resources that are both internal and external to the Ministry – then we can plan and aim for the following milestones:

• April 2024 – Define the core healthcare services to be included in the benefits package for all residents,
• April 2024 – Understand the demand and cost to deliver the core care services and develop payment model options for the core care services as well as consider wider health system financing,
• July 2024 – Undertake financial analysis to baseline and then model options for the Core Care Benefits Package; also, evaluate the economic impact of the options
• September 2024 – Recommend to Cabinet the most suitable and sustainable option enabling delivery of the Core Care Benefits Package, ensuring costs meet resources (both system and individual), and,
• April 2025 – Adopt a phased approach to implementing the Core Care Benefits Package starting with basic core benefits for all.

Mr. Speaker,

Honourable Members will recall the initial roadmap to achieve universal health coverage proposed that Bermuda adopt an approach comprising a ‘thin layer’ of coverage for everyone. From there, additional healthcare services would be built out and added until the Core Care Benefits Package is complete.

That is the approach the Ministry continues to advocate for, recognising that, over time, benefits will adjust in accordance with our population’s health needs.

Mr. Speaker,

The above list of milestones represents an ambitious timetable, and it will be reviewed and reprioritised as necessary. However, this Government continues with its commitment to universal health coverage to ensure that all Bermuda residents have access to essential, quality health services when they need them, without suffering financial hardship.

We look forward to working collaboratively and constructively with the UHC Steering Committee, the Health Forums, and the many health system stakeholders to achieve the goal of universal health coverage and improved health outcomes for our residents within a strong, sustainable health system.

Thank you, Mr Speaker.