The accompanying report examines the St Helena Government (SHG) Health Directorate’s (the Directorate’s) provision of healthcare, in particular its performance in the provision of primary, secondary and tertiary care. It summarises the results of our performance audit that assessed, for financial year (FY) 19/20, (1) the indicators used by the Directorate to measure its performance, (2) what these indicators tell us about the Directorate’s performance and (3) how the Directorate is performing against international benchmarks.
Findings and Conclusions
We first assessed the suitability of the Directorate’s 28 performance indicators for FY 19/20, which included comparing them to indicators from England’s National Health Service (NHS) and other overseas benchmarks. We found that while each indicator was measurable and aligned with strategic priorities, they could be improved in several ways. In general, the indicators tended toward measuring the relative availability of services, and how quickly they were delivered, as opposed to the quality or effectiveness of the services themselves. However, we also found the indicators and associated targets had become more refined over the past several years.
In terms of performance against its indicators, the Directorate met 17 of its 28 targets for FY 19/20. For example, the Directorate had some success addressing diabetes in St Helena’s population, but it is not possible to assess its progress in tackling other long-term conditions such as hypertension and kidney disease. Notably, the Directorate’s ability to monitor its performance is hampered by its electronic patient record systems, which do not meet its needs with respect to recording health data, test results, waiting times and other patient-related information. A full accounting of the Directorate’s performance on its 28 indicators is included in report Appendix Two.
We then looked at access to care against international benchmarks. While the Directorate is unable to provide complete data on waiting times for patients in both primary and secondary care, the information we gathered suggests that when the Directorate is fully staffed, St Helena residents generally enjoy expedited access to medical care relative to people living in England. The data we collected for FY 19/20 indicates that St Helena’s waiting times for routine appointments were shorter than those of the NHS and waiting times for surgeries were on par if not better. The Directorate could not measure waiting times for A&E or walk-in patients at the hospital.
Compared to the rest of the world, in FY 19/20 St Helena had a below-average number of doctors relative to its population but an above-average number of nurses and midwives. In a typical month this equated to 1.64 doctors per 1,000 people (the global average was 1.95) and 8.18 nurses and midwives per 1,000 people (the global average was 4.52). In addition, the relative proportions of clinical and non-clinical staff were nearly identical to those in the NHS. A former Chief Medical Officer told us the number of medical doctors here is appropriate (when fully staffed) but the skills mix may need to be re-calibrated in order to offer sufficient access to both general practitioners and specialist care. Meanwhile, various challenges hamper recruitment of doctors to St Helena – for example, doctors’ opportunities for professional development here are limited. We also found that local regulations governing recruitment of medical doctors that changed in 2019 require further revision to ensure that doctors practicing in St Helena have acceptable qualifications, given that there is no independent regulatory body here to serve as a gatekeeper verifying qualifications like the General Medical Council does in the UK.
We also benchmarked St Helena healthcare against other overseas territories. For example, St Helena’s per capita spend on healthcare was £1,929, which was more than Ascension Island at £1,363 and less than the Falkland Islands at £3,092 (recognising that those territories have very different economies and populations). In general, St Helena’s per capita spend was lower than in many developed economies. However, its facilities compare favourably to those in our sample of other overseas territories.
The Directorate’s performance should be considered in the context of its budget and spend. As with many government departments in St Helena and around the world, the Directorate spends a significant portion of its funding on personnel: the Directorate’s personnel costs amounted to 46% of its total spend. Technical Cooperation specialists (TCs), such as doctors and senior nurses, represented the Directorate’s single largest expenditure in FY 19/20, including recruitment, relocation, salary and allowances, and short-term consultants who are also funded from the TC budget. This £3.0 million expenditure also accounted for 37% of SHG’s £8.2 million total TC spend. The Directorate spent about the same amount on TC medical doctors (£1.0 million) as on all local staff. Overseas medical care was another major cost driver in FY 19/20, with overseas treatment and emergency medical evacuation together amounting to £2.2 million – 25% of the Directorate’s total spend.
Once TC costs are taken into account, the Directorate’s share of SHG’s operating spend for FY 19/20 was 22% – £8.8 million of SHG’s £40.6 million. Looking back over recent years, the Directorate’s share of SHG’s operating spend increased from 19% to 24% from FY 15/16 to FY 16/17 and then declined slightly through FY 19/20. (We use ‘operating spend’ to mean actual recurrent expenditure excluding pensions and benefits.)
Chief Auditor Brendon Hunt said today: “Providing healthcare in remote locations like St Helena is a difficult undertaking, as an extensive and diverse range of primary, secondary and tertiary care must be delivered by a mix of permanent and temporary staff working with constrained resources. The Health Directorate performed reasonably well against its indicators and overseas benchmarks in FY 19/20, but could improve its monitoring of the population’s access to basic healthcare services. This will be made easier by an electronic patient record system that is fit for purpose. The configuration of existing systems to enable the provision of this data should be a high priority for leadership. Further, because high levels of care – including overseas referrals – come at a high cost, the fiscal sustainability of the present funding model for an aging population is in question. As such, SHG should explore revenue-raising options like national healthcare insurance to preserve and strengthen this important service for the future.”
For more information, please contact David Brown, Principal Analyst by email or telephone on +290 22111.