What commvita would provide, what would be genuine build, and where a regional alternative is ahead — with the gaps stated beside the strengths, because a ministry choosing a platform is choosing what it is committed to in ten years.
A platform decision is usually presented as a feature comparison. It is more useful to start with a question the Ministry cannot currently answer, because that is what a platform is for:
For a small island this is the largest and least instrumented line in the health budget. It is also the one place where an electronic medical record structurally cannot help: the treatment happens in someone else's hospital, in someone else's system, in someone else's currency. The record of what was spent, what was authorised, who travelled with whom, and what came back is a coordination record, not a clinical one.
That is the layer commvita provides. The formulation we would put to the Ministry is deliberately narrow:
commvita is proposed as a national health and social care coordination layer sitting above and alongside the existing medical record, not in place of it. There are three reasons, and only the third is about commvita.
| Reason | Why it matters to the Ministry |
|---|---|
| Replacing a working record is the highest-risk change available | Clinical continuity is put at risk to solve a coordination problem. The coordination problem can be solved without touching the record. |
| The unanswered questions are not clinical | Overseas spend, household vulnerability, benefit eligibility and safeguarding are cross-agency questions. No medical record is designed to answer them, and none should be asked to. |
| commvita is built as a coordination layer | Its spine is a person and an organisation, not an encounter. That is an architectural fact, not a positioning choice. |
Where this argument is weaker, stated plainly. Against a pure medical-record supplier this is a strong distinction. Against a national digital health platform that is both record and coordination layer, it is not a distinction at all — and at least one such platform exists in the region. Section 7 addresses that directly rather than avoiding it.
The following is taken from the platform's own provenance register, which is generated from page source and enforced in the build — a page cannot claim to read live data that it does not fetch. Three states are used, and the middle one is the honest answer where a surface does both.
A third state, beyond the key above. Live and demonstrated cannot express absent, and a document that has to choose between them for something unbuilt will always choose the flattering one. A coral marker therefore means not built — not built and not seeded, with the work named in section 5.
| Capability | Where it lives | Status |
|---|---|---|
| Overseas care and off-island referral | /patient-transport | Live — 15 endpoints, 5 persisted record types, full lifecycle from request through eligibility, approval, travel, escort, accommodation and reimbursement |
| Financial recovery and savings programme | /financial-recovery | Live — approval gates, five delivery figures reported separately, validated savings derived from finance records |
| Professional credentials and workforce assurance | /regulatory-engine | Live — and already resolved per jurisdiction, failing safe rather than assuming another country's regulator |
| Governance, audit and board assurance | /board-assurance-framework, /report-registry | Live |
| Emergency preparedness and business continuity | /eprr | Live — framework resolved per jurisdiction with neutral framing, not NHS branding |
| Aggregate indicator reporting (DHIS2 shape) | /aggregate-reporting | Built, never exercised against a running DHIS2 server — see section 7 |
| Care coordination and long-term conditions | /int, /cases, /ltc | Mixed — real record spine, several illustrative surfaces |
| Safeguarding and vulnerability | /safeguarding | Mixed |
| Telemedicine coordination | /telehealth | 11 endpoints exist; the interface does not yet call them. Wiring, not building. |
| Citizen and household record | — | Not built to the standard this proposal needs. See section 5. |
| Social protection and benefits | — | Not built. See section 5. |
The overseas pathway was already recorded end to end: the request and its clinical justification, the eligibility decision, the approval, air or sea travel, fit-to-fly, the escort and their clinical authorisation, accommodation, the receiving hospital, the return, and the patient's own reimbursement for taxis, lodging and meals.
Two things were missing, and they were exactly the two that answer section 1: what the treatment cost and what happened to the patient. Both are now recorded. The register can therefore report, per episode and in aggregate, what the programme spent and what it achieved.
| Rule | Why |
|---|---|
| They are never combined into one figure | There is no cost-per-outcome, no value score and no return-on- investment number. A completed cardiology procedure and a cancelled orthopaedic appointment are not units of the same thing. A single ratio would be quoted in a budget paper as though it settled the question. Cost and outcome sit side by side and the Ministry does the judging. |
| Costs are never summed across currencies | commvita holds no exchange rate and will not invent one. Totals are reported per currency. Overseas treatment is frequently invoiced in the destination's currency, not the island's. |
| Quoted, invoiced and paid are three different claims | They routinely differ by a lot. A figure carrying none of them reads as settled when it may be an estimate nobody has agreed, so the basis is required. |
| An uncosted episode is named, never absorbed | Treating a missing cost as nought is how a programme comes to look cheaper than it is. The episodes with no cost recorded are listed. |
| Travelled but not treated is its own outcome | A patient who flew and was turned away has cost the programme a flight and bought nothing. That is the single most important row for a ministry to be able to see, so it is not folded into a general “incomplete”. An outcome cannot be recorded before the patient returns, and requires a named assessor. |
What this does not measure, stated in the interface itself. It cannot price the counterfactual — the cost of not referring. It does not adjust for clinical severity, so a completed outcome on a straightforward case counts the same as one on a complex case. It does not capture onward costs incurred on-island after repatriation.
Two of the capabilities this proposal rests on do not exist to the standard described. Saying so in the architecture document rather than at implementation is the difference between a plan and a surprise.
commvita has a household object, and it is thin: a reference, an address label, the members and a size. It carries no family or carer relationships, no dependants, no income, no eligibility status, no consent and information- sharing preferences, and no links to education, police, housing or the courts. It is also keyed on a United Kingdom statistical geography that Montserrat does not have. This is a build.
An architectural recommendation specific to Montserrat. At this population, statistical population health is the wrong tool. You do not need deprivation deciles and risk-stratification models to find the people who need attention — you can enumerate the island. The population layer should be a list with rules, not a model with cohorts. That is simpler, cheaper, more accurate, and it means the UK geography should be replaced by a real address and household key rather than ported.
The proposal correctly identifies this as where a coordination layer earns its place, because welfare assistance, medical assistance, grants, rental assistance and probation are precisely what a medical record cannot hold. commvita does not have it. The financial-assessment surface does not persist what it is given, and the means test carries thresholds from another jurisdiction's statute in another currency.
Building it properly means a rules-based eligibility workflow with the thresholds held as configured, dated, sourced values in the local currency — not constants in code — with human override and recorded rationale, and an audit trail of who decided what and why.
We would invert the ordering most proposals use. Phase one should be things that already work, so the Ministry sees a working system quickly and the risk sits in phase two where it is visible and budgeted.
| Phase | Contents | Nature |
|---|---|---|
| 1 | Overseas care with cost and outcome · professional credentials · governance and board assurance · emergency preparedness and continuity · integration assessment against the existing record | Configuration and integration of capability that exists |
| 2 | Citizen and household record with relationships and eligibility · social protection workflow in local currency · telemedicine interface wiring · citizen index wiring | Genuine build. Scoped, costed and scheduled as such |
| 3 | Citizen portal · self-service · outcome-based commissioning · essential services basket modelling | Extension |
Emergency preparedness is in phase one deliberately. Given Montserrat's volcanic and hurricane exposure, continuity and offline operation are a first-class requirement rather than a later refinement.
A national digital health platform is live in the region. We read its public build directly rather than characterising it from memory, and the Ministry should have the result unedited.
| Point | Position |
|---|---|
| ICD-11 and DHIS2 | Conceded. That platform has both, including the real DHIS2 aggregate payload format and a stated live connection to a national DHIS2 instance. commvita has built both, and neither has been exercised against a running upstream server. On this point they are ahead and we say so. |
| Clinical scope | Conceded. It carries order entry, decision support, blood bank and sterile services. It is both record and coordination layer, so “we do not replace your record” is not a differentiator against it. |
| Health and social care | This is the difference. Across its entire public build there is no overseas or off-island care, no repatriation, no household, no means test, no eligibility, no social protection, no safeguarding and no carer record. Those are the four things this proposal is built on. |
| How each supplier reports its own maturity | Their standards register publishes a self-declared implementation status of “full” and a compliance percentage for a terminology standard. commvita does not publish self-assessed compliance percentages; where something is built but unverified, the interface says so. The Ministry may reasonably ask both suppliers the same question: which of you will tell me when something is not working? |
Commercial shape. The Commvita Flow Edition is £1 per instance, with optional paid support. It is priced per instance rather than per seat, which matters disproportionately at this population: the cost of covering the whole island is the cost of covering one clinic.