The Cayman Islands Hospital is too old and too small and "we need a new hospital in the near future", the Health Services Authority (HSA) told the Public Accounts Committee (PAC) on September 9 – hours before the Ministry of Finance told the same committee it will keep a healthcare liability of more than CI$2 billion off the face of government's accounts because recognising it would wipe out much of the operating surplus.

The two statements are connected. The liability is the actuarially assessed cost of healthcare that government has promised its retired civil servants and their dependants, most of it to be delivered by the very hospital HSA chief executive Lizette Yearwood says is reaching the end of its life.

Ms Yearwood told the committee that patients are already transferred to private hospitals when the hospital's beds run out, that acute mental health admissions among teenagers have risen sharply since the pandemic, and that HSA remains the only facility in the islands able to admit them. A four-bed adolescent unit is due this year; Cabinet has set aside CI$5 million to begin a purpose-built acute mental health facility, with procurement not expected until 2027.

She also said the pharmacy had cut stockouts from 180 items to 22, of which 10 have since been resolved – but she could not tell the committee which 12 drugs patients still cannot get. She undertook to supply the list.

The bill nobody will book

Acting Financial Secretary Michael Nixon told the committee the ministry would not adopt a long-standing Auditor General recommendation to recognise the post-retirement healthcare liability, valued every year since 2011, on the balance sheet rather than in the notes. Doing so, he said, "will have a very material impact on our operating surplus" and could put government in breach of the Framework for Fiscal Responsibility. Successive finance ministers had been asked, he said, and each time the answer was to leave it in the notes.

Chris Saunders MP, a committee member and former finance minister, said he had made that decision himself – but not for that reason. The figure, he argued, only holds if government did not own the hospital; since it does, and already supplies 70% to 75% of its revenue, recording "a figure like over $2 billion in one go" would be misleading. PAC chairman Roy McTaggart MP, finance minister from 2017 to 2021, warned that the dispute was easily misread as government refusing to acknowledge its debts and asked the ministry to publish its reasoning alongside the figure.

Neither man disputed that the promise exists or that it will fall due.

Nine years without a plan

The hospital is not the only part of the health system running without a map. Deputy Chief Officer Bobeth O'Garro of the Ministry of Health, Environment and Sustainability confirmed that Cayman has had no national health strategy since 2017 and that the Pharmacy Act, passed by Parliament in 2024, still cannot be brought into force because its regulations are not written. Both are now promised for the second quarter of 2027. Asked how many Caymanian doctors government had helped to become board certified, she could not say, and confirmed there is no ministry grant for it.

What else slipped

The health items were the most immediate of 249 audit recommendations that government accepted, some as long ago as 2015, and never delivered. Auditor General Patrick Smith told the committee 57% have been outstanding for more than five years, and only three of 33 formal Government Minutes due to Parliament were tabled on time.

Among the rest: outcome-based budgeting, first promised for 2023, will now not arrive before the 2030/31 budget; Mr Nixon could not say what consultants EY have so far been paid to design it. There is no written policy on the duty concessions granted to developers and no check on whether promised benefits materialise, and Mr Nixon could not recall one that required the employer to hire Caymanians. At the Ministry of Social Development and Innovation, Chief Officer Nellie Pouchie conceded the department can count the households it helps but not whether the help works, 11 years after being asked to measure outcomes; pressed by Kenneth Bryan MP about a retired couple in his Prospect constituency refused assistance and unable to run their air conditioning, she said a review of the CI$3,000 monthly income threshold is with the minister.

Deputy Governor takes on the auditor

Deputy Governor Gloria McField-Nixon, two months into the job, accepted that the civil service had "fallen short" but publicly rejected the Auditor General's warning that the backlog raises the risk of fraud and waste. "I do not believe that the number of outstanding recommendations by itself is a reliable measure of fraud risk," she said, arguing that many recommendations were too vaguely worded ever to be closed and that government should say so: "No is an answer."

She said 61% of the remaining recommendations had now been self-reported complete and that seven overdue Government Minutes would be tabled when Parliament sits on September 30. The Auditor General's office will test those claims later this month.

Still proving you are Caymanian

One grievance cut across party lines. Deputy Chief Officer Charles Brown, who leads the e-ID project, confirmed that Caymanians born after 1977 must still obtain a letter of acknowledgement from Workforce Opportunities and Residency Cayman before the new card can show their status, because no other government database – including the voters' list – can legally establish who is Caymanian. Mr Saunders said he had refused to get one and would not ask his constituents to. Mr Bryan, born in 1980, said he did not accept that he should have to ask "any government department to say confirm whether I'm Caymanian".

The committee will report to Parliament. HSA has undertaken to publish the list of unavailable drugs and to post pharmacy wait-time targets in every location.