Major debate over future of Manx Care as audit exposes structural and financial failings

Calls for clearer governance, long-term funding and united leadership

Tynwald has debated an independent review that concludes the Island’s current health and social care model is not operating as intended, four years after the creation of Manx Care.

The Mersey Internal Audit Agency (MIAA) report found structural, financial and governance weaknesses across both Manx Care and the Department of Health and Social Care (DHSC), and outlines four strategic options for reform.

The report states that the Island’s size, governance arrangements and funding mechanisms have limited Manx Care’s ability to function as a fully arm’s-length body.

It highlights issues including instability within the DHSC, unclear funding formulas, strained relationships between key departments, and a governance framework that was never fully developed when Manx Care was established in 2021.

Auditors explored four possible future models: doing nothing, fully implementing the Sir Jonathan Michael review, strengthening the partnership between DHSC and Manx Care, or reintegrating the two bodies. Options two and three were assessed as the most viable, with stakeholders reportedly favouring a strengthened partnership approach.

Members agreed to receive the report and that the DHSC will report to the February 2026 sitting of Tynwald for debate with a full response and implementation plan.

Opening the debate

Health Minister Claire Christian told the court that maintaining the status quo is not a viable option, describing the moment as a call to action. She says the question before members was not whether change should occur, but how government should act and in which direction.

Speaker of the House of Keys Juan Watterson says the Island had repeatedly faced the same problems identified in earlier reviews, some stretching back nearly two decades. He says issues such as unclear accountability, poor-quality data and a lack of long-term operational planning had persisted despite previous interventions. While acknowledging progress in areas such as cost-improvement work, he argued that government must now invest in core systems - particularly activity-based costing - to resolve long-standing financial uncertainty around Manx Care’s budget.

Former Health Minister Lawrie Hooper told members the review confirmed what previous reports had already made clear: that the DHSC had never been adequately supported at the top level, particularly in its financial capacity. He says repeated studies had delivered the same message - to fix long-term funding - and warned that without a commitment to multi-year budgeting, overspends would continue indefinitely. Without such a change, he says, the work of Tynwald “is not worth our time”.

Chief Minister Alfred Cannan says he welcomed the timing of the review, describing it as an important opportunity to reassess how the system was functioning. He thanked frontline staff but questioned why operational issues continued to dominate political debate if Manx Care had a professional board in place. He says financial scrutiny was being duplicated across Manx Care, the DHSC and Treasury, creating confusion about accountability.

Greater alignment and clearer governance were needed, he says, to prevent the Island from “going in an endless circle”.

On long-term funding, Mr Cannan says any commitment had to recognise wider affordability concerns, warning that rising healthcare costs were outpacing economic growth. If that trend continued, he says, government could face difficult decisions about taxation, spending priorities or how healthcare is funded in the future.

Further contributions

Garff MHK Andrew Smith says the report was long overdue and expressed frustration at repeated reviews failing to produce resolution. He says it was “very unfair” to expect the health minister to answer questions on matters over which she had limited control, given Manx Care’s independent board structure.

Treasury Minister Alex Allinson questioned the role of the Manx Care board within the overall governance framework. He says calls for multi-year funding needed to be accompanied by confidence in Manx Care’s ability to remain within budget and says significant investment had already been made in recent years. A historical focus on Noble’s Hospital had, he says, diverted resources from primary care, and rebalancing the system remained essential. Despite pressures on healthcare workers, he says funding must be transparent and aligned to need.

Arbory, Castletown and Malew MHK Tim Glover says the arms-length structure was “clearly not working as intended” and needed examination. He says the roles of the DHSC and Manx Care had never been properly defined, leading to the two bodies and Treasury operating as “three separate entities” with low trust between them. He says a unified five or ten-year strategy, stronger leadership and clearer communication frameworks were required, alongside greater engagement with clinicians.

Douglas South MHK Sarah Maltby says the funding model was central to the long-term success of services. She described comments made by the Chief Minister to the Speaker as unnecessary, saying members needed to either commit to longstanding recommendations or accept that no action would be taken. Her message to government was: “stop wasting time and deal with the issue”.

Douglas Central MHK Chris Thomas asked for greater clarity about the appropriate role of politicians, saying intermittent political involvement was unhelpful. He called for long-term settlement across all departments and says political input should focus on policy choices rather than operational matters. While supporting the report, he says the Island had relied too heavily on consultancy reviews and needed to evaluate transformation programmes more effectively.

Onchan MHK Julie Edge says the report marked a decisive moment for the future of health services. She says many residents and clinicians were facing unacceptable waits and increased costs, with more people being advised to seek private treatment.

She says evidence from the Isle of Man Medical Society made clear the current model was not fit for purpose. The report showed blurred accountability, misaligned funding, overburdened boards and a disconnect between planners and frontline clinicians, she says.

Ms Edge also says the DHSC had not been structured properly following the creation of Manx Care, and the relationship between the DHSC, Manx Care and Treasury had become confused. She argued that baseline costs of population need must be established before future demand could be planned and says overspends reflected management failure rather than frontline performance.

Minister responds

Responding to the debate, Claire Christian says the contributions had been valuable to the DHSC. The public needed to see that government had a clear plan, she says, and members appeared united in recognising the need for resolution. She says a multi-year funding model was essential to allow the DHSC, Manx Care and Public Health to plan effectively and engage with Treasury on the basis of clear baseline requirements. Without fundamental planning structures, she says, the system would struggle to gain public trust or Treasury confidence.

Separately, last month Manx Care was contacted for comment on the contents of the report and said the following:

"Manx Care welcomes the opportunity to review governance arrangements and reflect on how effectively the current delivery model is working as we continue striving to provide sustainable, high-quality services for the people of the Isle of Man.

"The report confirms that “Manx Care as a delivery model is the right model” and notes that stakeholder interviews have highlighted notable improvements to health and social care services since Manx Care’s establishment.

"Manx Care welcomes this review and supports greater partnership working with DHSC and wider government which will enable our health and care system to operate with greater quality and efficiency, achieving improved outcomes for the population we serve."