Member of Parliament on the island of Montserrat, Dr Ingrid Buffonge, presents her views on the Mott McDonald Report that details the prospects for Healthcare delivery on the island. You can listen to Dr Buffonge's report via audio below, or read the full text as also presented:
Greetings Montserrat this is Dr Ingrid Buffonge
I am hoping that your 2018 is going well so far. I know circumstances are challenging for many. I am making this address in particular today because of the damning health system and financing review recently completed for the government of Montserrat, now being called the infamous Mott McDonald report.
Many persons have already read it or heard of it. The report is not written from the point of view of progress in healthcare or small island development and sustainability, but rather it is a penny pinching report which be costly to the public and will not improve the quality of health care delivery. The report is about money – how dfid can spend as little as possible in healthcare.
The report has suggested very low budget options. My main major concerns are as follows:
1. Fewer Clinics. They have identified that too large a proportion of patients visit the casualty (1267 per 1000 population on Montserrat compared to 374 per 1000 in the UK). Its states that only 15% of attendances at Glendon are appropriate. They plan to close St Peters clinic.
2. The Mott McDonald team recommends that our new hospital really needs only 5 to 12 beds. To be generous they increased this to 15 beds and after the Ministry complained they increased it to 20 beds. We presently we have 30 beds in our hospital at Glendon in St johns.
3. The report does not recognize the importance of local CT scanning - the only CT option it can imagine is using Belmont’s old inadequate failing machine which they have since replaced. It is was failing and was not adequate for Antigua but it is somehow thought fit for us. They have also stated that Belmont will be responsible for service provision so that when the machine breaks down we will simply have to go to Belmont in Antigua. This will just continue the present situation of no on-island CT scanning.
4. The team recommends that all caesarian sections should happen off island. The only obstetric service locally will be the use of midwives. Midwife led obstetric services require a doctor, preferably an obstetrician to call on when complicated births occur. This has been proven to reduce perinatal mortality. At present the role is carried out by our general surgeon who is experienced in caring for obstetric patients. The team who wrote the report has somehow imagined that during a complicated birth the midwife will have time to take the mother to Antigua. This is impossible and is likely to result in a high death rate for newborns and their mothers rushing for medical evacuation while in the middle of a complicated delivery. In order for planned caesarian sections to take place off island pregnant mothers must travel abroad well before their due date. Who pays their living expenses for the time abroad before she has the caesarian (sometimes up to 2 weeks) and the days after she has the baby, who pays for their medical care abroad and who pays for their travel.
5. All paediatric surgery will happen off island, allowing only minor surgery to happen on island. This is ridiculous and sends a strong message that we are inadequate. We presently have a very competent surgeon who has been performing certain paediatric operations here for years. He performs well during emergencies and knows when to refer. He recently repaired traumatic liver lacerations in a child who was run over by a bus. The child is back at school and doing well. This surgeon has saved lives and has saved us money in performing operations here that the McDonald team would send abroad. This report is an insult to our surgical, anaesthetic and theatre teams.
6. One option recommended by the McDonald Team – the one which they have given the highest score to recommends the medical evacuation of all sick children requiring hospital admission. This is would be an unsafe practice that would be extremely costly for patients.
7. One option expects us to have a visiting anaesthetist only, daring to recommend that all surgery – adult and paediatrics happen off island.
8. The report recognises a high and increasing prevalence of diabetes and recognises that the number of renal failure patients requiring dialysis will increase but recommends that the government should have no plan for future government run dialysis. So if you don’t have access to a lot of money you wont be able to live on Montserrat or think about coming to Montserrat if you require dialysis. I recall the story of an elderly Montserratian man who returned home one year to sort out his financial affairs, he had left because of the volcano. He had been on dialysis in the UK and had plans of travelling to Antigua twice weekly to have dialysis while here. His plans for Antigua did not come through. He died at in the Glendon casualty. This failure to commit in any way to future dialysis sends a “don’t come here, or please leave” message to Montserratians with kidney failure – Diabetes and hypertension, both very prevalent in our population are two of the leading causes of end stage renal failure requiring dialysis.
9. The report identifies that the health service relies on a small number of clinical staff to provide 24/7 cover, has limited opportunities for staff training and continued professional development, inadequate clinical governance oversight and review (page 6) and minimum local access to diagnostic equipment but is unable to recommend anything positive to solve these problems. This report makes no commitment what so ever to the training and continued education needs of Glendon staff.
10. The McDonald team has realised that their recommendations have drastically increased the number of medical evacuation patients so they want us to hire another team to arrange the medical evacuation of each patient – more paying out of money and why? I can bet a non-local team would be hired for this.
12. The report points out that 40% of the population attending Glendon are in the exempt category. The government is paying for insurance cover for some of these same persons that it gives free healthcare to - it comes out if their salaries. The insurance company laughs, because it has to pay out nothing or next to nothing for local tests at Glendon for the exempt category. In general, Glendon’s fees are low because they are heavily subsidised. In addition many patients don’t or are unable to afford to pay their hospital bills. Thus when Glendon is looked at from an economic point of view it is doing badly. So this report is really about money – it is an economic analysis of health – telling dfid how it can make its best savings. In no way does it have the best interest of people who live here at heart. Nor does it care about progress in healthcare. The report cannot prove in any way that the options provided represent good health care. It is a HUGE step backwards for health. It will be extremely costly for patients and relatives. There will be increased liability – taking on the dangers of medical evacuation which offers suboptimal care and potential for disastrous care situations.
13. For all of this the report recommends that the government increases taxation in healthcare.
When the Ministry of Health presented this report to the public the responses were obviously negative. Most felt the report was fit only for the garbage. Citizens were concerned about the cost to patients and relatives – the cost of health care is very high abroad. Even patients with insurance, - they have to pay the healthcare bill, then the insurance company pays a certain percentage (often small). Some citizens were concerned about the low moral this sort of substandard health service would create, the message it sends to our Montserratians overseas, to visitors, to investors. One citizen brought up the question of mass casualty situations – the potential for a very poor healthcare delivery with inadequate beds etc. An economist in the audience lamented that people on Montserrat will be sending their money to Antigua – helping Antigua’s economy instead of our own. One commenter spoke of social costs involved that are a barrier to access to healthcare for many persons, being discriminatory and racist. That it warrants a social impact assessment – to see the effect it will have on the people. She mentioned that it is a legal requirement to be gender equality act compliant – it must not have a heavier impact on women. The recommendations in this report create a huge burden for women – inadequate care locally for themselves and their children.
The date on the report is the 3rd of November 2017. It’s a shame the report didn’t go directly on a Guy Fawkes bonfire on the 5th because this report attempts to assassinate all progress in healthcare and the development for our island. It is not only an insult to the people of this island but it will create financial hardship for patients and relatives on Montserrat, It will halt the development that this island desires making us appear to be something from out of the dark ages that no one wants to migrate to. It is likely to encourage migration in the opposite direction – migration out of Montserrat. We need a new hospital – don’t wrap us up in this cheap rubbish deal, signing away our island’s future, signing away the survival of our people. Do not encourage this attempt at genocide. Who will represent us in Parliament in 30 years time, you have to be born here to do this.
The Honorable Minister of Health has until January 25th to accept this report and to choose one of its ridiculous options. Please join me in ensuring that she does not agree to this document. Please contact your health minister and let her know that this report does NOT have your best interests at heart.