The scale may be smaller, but the nature of the challenges facing the health system of the Isle of Man are not dissimilar to those in our NHS.
Serving a population of fewer than 85,000, health services on the self-governing island, which is not part of the UK, are free at the point of use for residents.
”I think if we get it right we can become a beacon of modern integrated care”
Despite being highly reliant on nursing expertise, the Isle of Man is not immune to the workforce crisis.
Out of 455 substantive nurse posts in the Department of Health and Social Care (DHSC), 75 (16%) are vacant, with medical, children’s, intensive care and neonatal hospital wards particularly hard hit.
In addition, inappropriate use of acute services and an ageing population means the DHSC is struggling to contain escalating costs.
With the number of over-65s expected to increase by 75% by 2035, leaders are setting their sights on a complete overhaul of the island’s health system.
The revamp is in response to an independent review by former NHS trust chief executive Sir Jonathan Michael.
In his landmark report published in April, Sir Jonathan determined that the current system of health and care on the island was “both clinically and financially unsustainable”.
The government has agreed to implement all 26 of his recommendations, and has launched a major transformation project, backed by £5m in funding.
Crucially, this will involve establishing Manx Care, a new body similar to the NHS, to deliver services at arm’s length from the government.
Health minister David Ashford said this project was a chance to press the reset button.
Sitting in a small and unassuming office in what was once the island’s maternity block but is now the DHSC headquarters, Mr Ashford said the ambition was to become a fully integrated health and social care system, “and that means much more nurse-led services”.
“I think it’s a huge opportunity and I think if we get it right we can become a beacon of modern integrated care,” he said.
He said like in the UK, care on the island was “still very acute-focused” and he wanted much more to be delivered in the community.
“Because you are a very small tight knit community, you become like family on the ward”
While the UK has tried for years to integrate care, he said he believed the island had a true chance at success due to its size and structure of health services.
Comparing English health secretary Matt Hancock’s job to controlling an oil tanker and his own to driving a Morris Minor, Mr Ashford said: “We can effect change over here a lot more easily.”
As part of the initiative, Mr Ashford recently appointed a new director of nursing for the island to “be the voice” of the profession and have a seat at the executive table. It follows controversy over the axing of a previous chief nurse post last year.
Describing nursing as the “heart” of the island’s health service, Mr Ashford said he believed the transformation programme offered a chance for nurses to take on expanded and more varied roles.
“With a proper integrated system… you break down those barriers so it’s a lot easier if you are a nurse in the hospital to say ‘well actually, I’ve done 10 years working on the ward, I quite fancy going into the community’,” he said. “I think that makes it a lot easier then to be able to shift over because there’s not that silo mentality.”
Walking the near-empty corridors of Noble’s Hospital on a Friday afternoon, the calmness felt a million miles away from the busy and bustling units in the NHS.
As a registered nurse working in the island’s only acute hospital, Lucy Langford said her co-workers felt more like family than colleagues.
She made a career change into nursing after a devastating injury squashed her dreams of becoming a professional dancer.
When she tore the rotator cuff in her shoulder in the final year of university in England, studying ballet and contemporary dance, Ms Langford returned to her family on the Isle of Man to start a long recovery process.
The care she received from nursing staff ignited a passion she felt was already bubbling beneath the surface to enter the profession herself.
“I wanted to go into dance science, so I already had an interest in movement and the body and so it was always there in the sideline,” she said.
With an intake of only 20 students a year and courses usually oversubscribed, Ms Langford was lucky to get a place at the island’s only nursing school, Keyll Darree, based at Noble’s.
She qualified in September 2018 and has “absolutely no regrets” about settling on the island, which is located in the Irish Sea between England and Ireland.
“Working on the island from the nursing point of view, because you are a very small tight knit community, you become like family on the ward,” said
Ms Langford, who works in the hospital’s acute medical unit. Ms Langford praised the support available to newly qualified nurses on the island, who receive a year-long preceptorship package.
But what are the challenges? “Sometimes that you don’t get overall experience of a wider range of medical conditions,” said Ms Langford. This is because patients are sent to North West England for specialist or complex care.
Similarly, Sophie Merralls, a nurse on the female surgical ward, said it was a “shame” that she could not always follow patients through their whole care pathway, but staff understood that the hospital did not have the equipment or expertise to do everything.
She said telling patients they needed to go off-island was not always easy, noting how some Manx people had only ever received treatment at Noble’s Hospital and were dubious about going elsewhere.
With the size of the island, Ms Merralls said there was a sense that “everyone knows everyone” at the hospital – which presented both opportunities and challenges.
“I see a future where there are more specialisms in the community.”
She said the familiarity meant she could build better relationships with patients and the smaller wards meant she had more time to spend with them, enabling her to deliver truly person-centred care. Ms Merralls also said staff from all seniorities and departments were never too far away if problems occurred.
The quality of the emotional support and comradery was also high because staff worked so closely, said Ms Merralls.
“It makes those struggles much easier because you are not on your own, you feel like you are going through it as a team,” she said.
On the other hand, Ms Merralls said keeping work and home life separate could sometimes be difficult because staff were often spotted by patients in the street. Patients recognising each other in hospital could also pose a confidentiality risk.
While recognising that the working environment was more “laid back” than the NHS, Ms Merralls said there were still pressures, including around staffing.
The island relies on bank staff rather than agencies to fill nursing gaps but the bank consists mainly of nurses already working substantive posts in the hospital.
She said nurses would get a text nearly every day asking if they could pick up extra shifts but with the “family” feel of the hospital people were usually happy to help out.
Former NHS matron Sue Waddecar, patient safety and quality manager at Noble’s Hospital, said one thing she would like to happen on the island was the introduction of external regulation – a matter Mr Ashford has pledged to explore.
While nurses are regulated through the Nursing and Midwifery Council, there is currently no system regulator like England’s Care Quality Commission.
Meanwhile, district nurse Karen Shimmin said nursing shortages were not really an issue in the community.
She said community nursing was already hugely important on the island but she was excited about what the transformation programme would bring.
susan dunajewski and karen shimmin
“I think the healthcare service will change, I think it needs to,” she noted. “I see a future where there are more specialisms in the community.”
Ms Shimmin said being on a small island meant staff were already able to work in close partnership.
“We work really well with our other agencies, our occupational therapists, our physios, and that is such a benefit to the patient,” she said.
In a bid to address nurse shortages, the island is launching a recruitment campaign targeting the UK.
As part of this, the government is keen to emphasise its generous relocation packages for nurses moving to the island, including financial and housing assistance.
“When you look at Noble’s, it certainly is less pressured as an environment than it would be in a city hospital”
Low tax rates mean nurses’ take-home pay is usually higher and the island recently launched a “national insurance holiday scheme” in which nurses can apply for a refund on contributions for their first year working there.
Anne Shorrock, director of HR services at the Isle of Man Government, said the island had previously been shy about shouting about what it had to offer, noting how a lack of awareness often led to people confusing the Isle of Man with the Isle of Wight.
She highlighted how the island did not have a problem with retention; its voluntary nurse turnover rate is just 2.1%, but a lot of nurses are hitting retirement age.
While the island did grow its own nurses, Ms Shorrock said it was limited by how many places it could offer, so it had to rely on other countries to an extent. The island also only offered pre-registration training in mental health and adult nursing.
nicole and anne
Source: Isle of Man Government
The Isle of Man is seeking to capitalise on the challenges facing nurses in the UK with its recruitment material encouraging them to “step away from NHS pressures”.
“I think everyone feels like they are busy in their job; however when you look at Noble’s, it certainly is less pressured as an environment than it would be in a city hospital and lots of other areas,” said Ms Shorrock. “So we absolutely do have that benefit.”
The Manx Care programme could be an exciting lever to pull in ambitious nurses wanting to be part of something new, said Ms Shorrock.
“I think the notion of developing our care so that it fits around our patients and their needs, is a really attractive proposition for people in the care industry,” she added.