Let Us Hope We Do Not Make the Same Mistake Twice

Introduction

While I am grateful for the healthcare services that InterHealth Canada (IHC) has provided to the people of the Turks and Caicos Islands over the past sixteen years, I believe one of the biggest mistakes we made was entering into a Public-Private Partnership (PPP) contract that ultimately became so strained that its premature end now appears inevitable.

The Government had previously acknowledged that its relationship with IHC had become strained and that the contract could come to an end. That is why I was somewhat surprised by the apparent reaction of the Government to IHC’s public announcement that it had terminated the agreement. If my understanding is correct, contracts of this nature normally contain notice provisions before termination takes effect. If that is the case, this development should not have been entirely unexpected.

From a financial perspective, it may be better that IHC exercised its contractual right to terminate rather than TCIG doing so. Depending on the terms of the agreement, a Government-initiated termination could have resulted in greater financial exposure for taxpayers. Of course, I may be wrong.

The most important issue today is not who terminated the contract. The real question is: What lessons have we learned, and how do we ensure we never repeat the same mistakes?

Understanding the Funding Arrangement

One aspect of this dispute that has confused many people is the issue of payments.

In its press release, IHC stated that the Government had failed to make all required payments for more than eighteen months and that it could no longer continue providing healthcare services indefinitely under those circumstances. The Government responded by saying that statement was misleading because all clinical costs had been paid and that the sums withheld related to contractual performance issues concerning estates or facility services.
This distinction is extremely important.

Each year, IHC submits its clinical services budget to the Government. Once both parties agree on that budget, TCIG pays one-twelfth of the approved amount every month.

Clinical services generally include:

• Doctors and nurses.
• Medical supplies.
• Laboratory and diagnostic services.
• Patient care.
• Other healthcare operations.

In simple terms, Government funds the cost of delivering healthcare services and pays the contractual management fee agreed under the contract.

Clinical Payments Are Different from Facility Payments

Based on the Government’s press release and subsequent press conference, the payments currently in dispute appear to relate primarily to facility or estates services rather than clinical care.

Facility payments generally cover the non-clinical aspects of operating the hospitals, including:

• Financing and repayment of the hospital construction.
• Building maintenance.
• Utilities and engineering services.
• Lifecycle replacement of major building systems.
• Other non-clinical facility management services.

Under most Public-Private Partnership arrangements, these payments form part of what is commonly referred to as the unitary charge.

That distinction matters because anyone reading IHC press release could easily conclude that doctors, nurses and patient care have gone unpaid, when that does not appear to be the Government’s position.

The public deserves clarity because healthcare is too important for misunderstandings.

Communication Could Have Been Better

One of my biggest concerns is communication.

Whether one supports TCIG or IHC, the public should never first learn about a matter of this magnitude through a contractor’s press release.

Healthcare affects every resident and every visitor to these Islands.

If the contractual relationship had reached the point where termination was a real possibility, I believe the Government should have communicated with the public more frequently and prepared the country for a possible transition.

Good communication builds confidence. Silence creates uncertainty.

The Next Contract Must Be Different

As Government looks ahead to the next chapter in healthcare management, I hope it carefully evaluates the structure of any future agreement.

Public-Private Partnerships certainly have their place, particularly for major infrastructure projects such as hospitals and airports. However, I believe we should be cautious about entering into agreements that lock the country into arrangements lasting twenty-five or even thirty years.

Healthcare evolves rapidly. Technology changes. Population demands increase. Governments change.

Future contracts must provide sufficient flexibility to adapt to changing circumstances without creating years of conflict between the parties.

A Public Review of the PPP Agreement Is Essential

One of the first things the Government should do after this matter is resolved is commission and publish a comprehensive “lessons learned” review of the Public-Private Partnership agreement.

The objective should not be to assign blame to either TCIG or InterHealth Canada. Instead, it should objectively assess what worked well, what did not, and what improvements should be made before another long-term healthcare contract is signed.

Among the questions that should be answered are:

• Did the PPP arrangement provide value for money?
• Were performance standards properly monitored and enforced?
• Were disputes identified and resolved early enough?
• Were the financial responsibilities of both parties clearly understood?
• What contractual provisions contributed to the deterioration of the relationship?
• What safeguards should be included in future agreements?

Where legally and commercially appropriate, the review should also include a financial summary of the agreement so taxpayers understand how public funds were spent over the past sixteen years and the value received.

Healthcare is one of Government’s largest public investments. We owe it to future generations to learn from this experience.

Transparency is not about dwelling on the past; it is about building a better healthcare system for the future.

Invest More in Local Healthcare

Regardless of who manages our hospitals, one issue remains clear, we must continue investing in healthcare here at home.

Every dollar invested in expanding local healthcare services is potentially a dollar saved on overseas treatment. More importantly, it means our people receive care closer to their families and support systems.

I cannot speak on behalf of Government, but one could reasonably question whether the strained contractual relationship influenced the pace of investment in expanding local healthcare services. If so, that would be unfortunate because healthcare decisions should always be driven by what is best for patients, not by contractual disputes.

The Closure of Myrtle Rigby Health Complex Was a Missed Opportunity

One decision that I have always questioned was the closure of the Myrtle Rigby Health Complex.

While the construction of Cheshire Hall Medical Centre and Cockburn Town Medical Centre represented a significant step forward, I believe closing Myrtle Rigby altogether was a missed opportunity.

The facility could have continued serving an important role by providing primary healthcare, outpatient services, chronic disease management, specialist clinics, rehabilitation services, dialysis support and additional bed capacity during periods of high demand or public health emergencies.

The COVID-19 pandemic reminded us that healthcare capacity matters.

As our population continues to grow and our tourism industry expands, the demand for healthcare services will only increase. Having additional healthcare infrastructure is not a luxury but it is a necessity.

Retaining Myrtle Rigby would also have provided Government with greater operational flexibility while reducing pressure on Cheshire Hall Medical Centre. It could have complemented the new hospitals rather than replacing them entirely.

One concern with long-term PPP agreements is that Governments can sometimes become reluctant to expand public healthcare facilities because of the financial commitments tied to the existing contract. Whether that was the case in the Turks and Caicos Islands is a question worth examining as part of the proposed review of the PPP agreement.

Future healthcare agreements should never prevent Government from expanding healthcare services whenever the needs of the country require it.

Planning for the Future

The end of this contract presents an opportunity not just to negotiate another agreement, but to rethink our entire healthcare strategy.

We should strengthen primary healthcare, invest in additional diagnostic and specialist services, expand local treatment options, reduce dependence on overseas referrals and ensure that any future healthcare partnership is built on accountability, transparency and flexibility.

Healthcare should never become a source of uncertainty for our people.

Conclusion

Eventually, the legal issues between TCIG and InterHealth Canada will be resolve. Therefore, what matters most is that patients continue receiving quality healthcare without interruption.

I also believe the Government should be the first to communicate major developments of this nature to the public whenever possible. While legal considerations may sometimes limit what can be disclosed, timely communication builds confidence and reduces unnecessary speculation.

Finally, I wish to thank InterHealth Canada, its doctors, nurses, healthcare professionals and support staff for the service they have provided to the people of the Turks and Caicos Islands since 2010. Regardless of how this contractual dispute is ultimately resolved, their contribution to healthcare in these Islands should be acknowledged and appreciated.

The end of the IHC contract should not simply mark the end of one agreement. It should mark the beginning of a better approach to healthcare, one that is more transparent, more flexible, more accountable and more focused on the health and wellbeing of the people of the Turks and Caicos Islands.

Let us learn from the past so that we never make the same mistake twice.