Jersey Care Model [P.114/2020]

STATES OF JERSEY

JERSEY CARE MODEL

Lodged au Greffe on 22nd September 2020 by the Minister for Health and Social Services

STATES GREFFE

2020  P.114

PROPOSITION

THE STATES are asked to decide whether they are of opinion

1. To receive the Jersey Care Model (JCM) (as set out in Appendix 1 to the report accompanying this proposition), the Jersey Care Model Review (as set out in Appendix 2 to the report accompanying this proposition) and JCM Strategic Outline Business Case (as set out in Appendix 3 to the report accompanying this proposition), and to approve the strategic objectives of the Jersey Care Model set out on page 4 of the report accompanying this proposition.
2. To note that Ministers intend to bring forward proposals for investment in the Jersey Care Model in the Government Plan 2021-24, and subject to that investment being approved, to:

1. approve the proposals to move to the next stage of the programme, to progress to the detailed design and phased implementation of the  Jersey  Care  Model,  as  defined  in  the  Strategic  Outline Business  Case  and  summarised  on  page  28  of  the  report accompanying this proposition; and
2. to request the Council of Ministers to co-ordinate the necessary steps  by  all  relevant  Ministers  to  bring  forward  for  approval proposals for a sustainable funding model for health and social care, to be operational by the end of 2025.

MINISTER FOR HEALTH AND SOCIAL SERVICES

Page - 2

P.114/2020

HEALTH AND COMMUNITY SERVICES JERSEY CARE MODEL

Proposition Report

CONTENTS

Introduction ............................................................................................................................................................ 3 The Jersey Care Model ....................................................................................................................................... 3 Jersey Care Model Strategic Objectives.................................................................................................................. 4 How does this align with Government Strategy? ................................................................................................... 5 Why does Jersey need the JCM? ............................................................................................................................ 6 How will it differ from the present system of care? ............................................................................................... 9 Current System ................................................................................................................................................... 9 Future Care ....................................................................................................................................................... 11 Examples of the JCM in Practice ........................................................................................................................... 14 Jersey case study examples OF services that need to be expanded as a core offering ...................................... 14 Primary Care Mental Health & Social Prescribing ............................................................................................ 14 Mental Health – Community Outreach ............................................................................................................ 14 Community Respiratory Team .......................................................................................................................... 15 Rapid Response ................................................................................................................................................ 15 Closer to Home ................................................................................................................................................. 15 UK case studYexamples OF services that need to be developed as a core offering............................................. 16 Social Care – Personal Budgets ......................................................................................................................... 16 Social Care - Reablement / Frailty .................................................................................................................... 16 Social Care - Reablement / Stroke .................................................................................................................... 17 Different ways of working with Primary Care, Examples (not actual patient Stories) ......................................... 18 Long-term conditions management e.g. diabetes ............................................................................................ 18 Rapid Access to Community Services ................................................................................................................... 18 How can we know it will Work? ........................................................................................................................... 19 PWC Methodology and Approach ........................................................................................................................ 19 Findings of the JCM Review .................................................................................................................................. 21 Benefits / Costs as validated by PWC ................................................................................................................... 23 Longer Term Funding & Budget Structures .......................................................................................................... 26 COVID – ImPACT and latest position with General Practice ................................................................................. 26 Implementation .................................................................................................................................................... 28 JCM ImplEmenTation Governance ....................................................................................................................... 30 PWC Findings of further opportunities identified in stress test ........................................................................... 31 Frequently Asked Questions ................................................................................................................................. 33

INTRODUCTION

The Minister for Health and Social Services believes the adoption of the Jersey Care Model (JCM) is an important development for the whole community and should have Assembly endorsement. Therefore, the Minister is seeking the Assembly's endorsement of the overall concept of the Jersey Care Model and its objectives, and is seeking the Assembly's approval to move into the next stages recommended by PWC, the Executive Management Team of the Health and Community Services Department (HCS) and the Council of Ministers.

States Members' input into the strategic direction is valued at this stage before a move into detailed design at a service level.

The Minister and the HCS Executive Management Team recognise that past operating environments have been difficult ones in which to implement change. However, we have recently seen successes in moves towards less reliance on bed-based care, resulting in lower occupancy at the Hospital. There has also been good progress on social care discharge pathways, and community outreach projects in both mental and physical health have shown positive results in preventing admissions. The journey through COVID-19 in the first half of 2020 has given all providers a much better practical understanding of the interconnections and the strong and weak points of our system, putting us in a much better position to develop good practice. We feel there is public support for ensuring that healthcare services are configured to be delivered resiliently, sustainably, safely and, in many cases, out of hospital. This is the ideal opportunity to make a coordinated, positive change to the Island's healthcare system.

THE JERSEY CARE MODEL

A care model is a conceptual framework which calls for an organised and planned approach to improving patient health. It sets out the high-level design for services, incorporating all elements of the health and care system, as a guide to improve services holistically. The care model helps create a consistent narrative by which all elements of the system can understand the direction of travel and coordinate integration. Healthcare by its nature is complex and never static. HCS has not stopped evolving services outside of this programme as it has reacted to changing environments. The Jersey Care Model (JCM) will inform a delivery programme which will develop and deliver integrated services that will be designed and delivered as an evolution rather than a revolution, using the care model as it's reference point.

The overarching aim of the Jersey Care Model is to transform health and social care, in order to improve Islanders' physical and mental health and wellbeing. To achieve this, it proposes adopting a patient-centred approach whereby care is financially sustainable, safe and accessible, being provided in the places where people need it the most.

This  also  aligns  closely  with  the  Government  of  Jersey's  Common  Strategic  Policy  –  in particular to improve Islanders' wellbeing and mental and physical health, whilst preparing for more Islanders living longer. Indeed, without the JCM, analysis suggests that the current health system would be overwhelmed as a result of the ageing population demographics and disease prevalence on the Island.[1]

Care will be enhanced in the community and decentralised from the hospital by strengthening public health, prevention and community services to reduce the dependency on secondary care. Care will be proactive rather than reactive and will put individuals at the centre of their own care. Technology will also be fully utilised to allow people to manage their own health. A strong partnership model will be developed with valued service providers across the public, private and community sectors.

JERSEY CARE MODEL STRATEGIC OBJECTIVES

The JCM has three overarching objectives, which are aligned with the Government strategic ambitions[2]. These are to:

1. Ensure care is person-centred with a focus on prevention and self-care, for both physical and mental health
2. Reduce dependency on secondary care services by expanding primary and community services, working closely with all partners, in order to deliver more care in the community and at home
3. Redesign health and community services so that they are structured to meet the current and future needs of Islanders

HOW DOES THIS ALIGN WITH GOVERNMENT STRATEGY?

Over the last decade, a series of papers and publications have set out the vision for health and care services in Jersey and developed the JCM to achieve this vision.

In 2011, Health and Social Services published the Green Paper Caring for each other, caring for ourselves[3]'. This set out a 30-year vision and a ten-year plan for health and care services on the island, including how health and care services would be modernised and expanded in the community to deliver more round-the-clock care with a view to reducing admissions.

It set out a desire to move towards a less medicalised and paternalistic approach to care and mirrored aspirations elsewhere in the world to better integrate services to provide a more joined-up approach. The intention was to support people to remain independent for as long as possible, reduce unnecessary hospital emergency visits and only admit people to hospital when  they  needed  to  be.  This  would  reduce  pressure  on  the  acute  hospital  as  our community's demographic changed. The Green Paper also acknowledged the need for a new hospital and, within this context, for the new care model to facilitate a shift to a more community-focused model of care at the point at which a new hospital was built. In 2012, this was developed into a White Paper[4] which developed the ten-year plan in more detail.

Following the publication of the White Paper, the Government of Jersey published Health and Social Services: a new way forward' (P82)[5]. This set out a clear case for change in the way services  should  be  delivered  in  order  to  be  sustainable.  This  White  Paper  has  set  the foundation for the strategic direction of health and social care on the Island.

The JCM builds on the foundations and principles of P82/2012 but brings it up to date with reference to modern practices and international best practice.

As highlighted in the PWC Review of the JCM [6], the Jersey Care Model is aligned with internationally recognised best practice examples and addresses issues in the current care model, with a fundamental shift to the provision of sustainable, affordable, safe and high- quality services. The JCM outlines a strong, person-centred approach to delivering healthcare in Jersey, in line with current trends in healthcare worldwide. The proposed integrated care model is likely to deliver enhanced service user experience and care by streamlining services and workforce resources.  

WHY DOES JERSEY NEED THE JCM?

Health and care are continuously evolving, and the practice of today isn't always practice for tomorrow.  Hospital  interventions,  community  capabilities  and  digital  innovation  are  all shaping the way health and care is delivered now and for the future. Jersey will need to adapt to these changes in order to attract the many professionals needed to provide care on the Island. The Global Pandemic in 2020 has shifted focus onto the resilience of health and care systems, and for Jersey has outlined that care out of hospital is as important as care in hospital.

International organisations[7] including the World Health Organisation (WHO), Organisation for Economic Cooperation and Development (OECD) and World Economic Forum (WEF), together with the EU Parliament[8] and British Medical Journal[9], have recently identified significant challenges to the long-term durability, performance and sustainability of healthcare systems. Ageing populations, increasing rates of chronic and complex disease, growing cost pressures from  new  medical  technologies  and  medicines,  wasteful  spending  on  low-value  care, inefficiencies due to system fragmentation and limited use of data and evidence to support reform have been identified as threats to health system performance and sustainability. Jersey is facing the same threats as the rest of the world in this respect. The cost of health care is also rising by around 4-10%pa[10] , which places a challenge on sustainability. Health and care systems are being forced to think differently about how to meet those challenges.

Whilst many health and care services in Jersey are performing well currently, there is room to improve and modernise in many areas; and services are not future proofed. The Island expects its population to grow by 13% between 2019 and 2030[11], with a growing proportion in age groups that have greater health and care needs. By 2036, around one in five of the population will be 65 or over. The result of this demographic change is likely to be a significant growth in those accessing services, particularly when the prevalence of long-term conditions in this group is taken into account (more than half of Islanders aged over 60 have

two or more long-term conditions[12]). It is therefore imperative that Jersey adapts to this demographic challenge by ensuring health and care on the Island is co-ordinated and directed to meet the care needs of Islanders.

With an ageing population, the cost associated with treating these diseases in Jersey is due to rise to unsustainable levels. Statistics Jersey's Disease Projections Report[13] predicts that a do nothing' approach will result in the following by 2036:

* Diabetes to increase by 42%

* Stroke to increase by 64%

* Dementia to double

* Chronic kidney disease to increase by 74%

* Chronic Obstructive Pulmonary Disease to increase by 50%

* Mental health conditions to increase by 29%.

As an island we are also an outlier compared to UK comparable regions in our high use of residential care, highlighting our lack of 24/7 community care to support independent living[14].

The current health and social care model is hospital-focused and based on an institutionalised model, with a high level of referrals to specialists leading to dependency on secondary hospital care for the provision of services. This was also recognised in P82/2012. This is evidenced by approximately 30,000 visits to the Emergency Department in 2018 that were not classified as emergencies requiring Hospital care and over 200,000 outpatient appointments per annum. Many patients and families describe the existing system of care as fragmented', with little continuity in care leading to multiple reviews by many professionals.

In addition to this inefficiency, there are further acknowledged issues with the current model, including[15]:

• Limitations in preventative care on the Island

• Lack of co-ordination between Primary and Secondary Care services and external partners can lead to transactional care for patients evidenced in multiple referrals and repetitive consultations

• Mental health services are not fully integrated with physical health and social care services

• Absence of 24/7 help and care for people to access, in particular overnight community nursing and carers who can provide a night sitting' service.

The JCM offers an opportunity to address these gaps and coordinate services across all parts of the system for an improved service user and care experience, and to invest in preventative services which will support Islanders in staying healthier for longer.

Given the rising cost of care, it is important for Jersey to make efficiencies to ensure public services offer good value and quality for Islanders. By 2036, the JCM is forecast to avoid £23m of recurrent annual expenditure growth for the health and care system[1]. Over the 16-year period modelled, the net present value saving associated with the JCM is estimated to be £118m.

HOW WILL IT DIFFER FROM THE PRESENT SYSTEM OF CARE? CURRENT SYSTEM

The development of the Jersey Care Model has identified several gaps within the current system of care which include;

Secondary Hospital Care Focused Model

• The Hospital is the centre of care for the island. There is evidence of extended Hospital length of stay for people who are medically fit and require care out of hospital and there is concern the current model focuses on institutionalised bed-based care.

• Emergency Department (ED) attendances – there is a high rate of attendance at ED with  relatively  low  acuity  which  demonstrates  that  many  attendances  could  be avoided – this is evidenced by the low conversion rate of admission to hospital when seen in the Emergency Department  

• The  Hospital  is  currently  underutilising  its  operating  theatres,  both  in  terms  of scheduling and use of day case theatre – this has been re-set due to COVID but there is still opportunity for improvement

• Rehabilitation / length of stay – there are long length of stays in rehab inpatient services which are also Hospital-based and there is a high flow rate into residential care direct from Hospital as a result of no alternative care being available

• Outpatients – the new to follow-up' ratio is high in comparison to benchmarks – suggesting that secondary care is not discharging into primary care and patients are having to continue to attend the Hospital outpatients for follow-up care

• Rapid response (a service to prevent people going into Hospital and help them to leave hospital when able) could be more optimised. This was a key part of P82 but the JCM has identified this service requires more investment

• Reablement to support rehabilitation services is limited due to the size of the service and it is not standard practice to assist people to live independently

• The current system is heavily reliant on beds, particularly for older demographic care which presents high risk of hospital-acquired infection, falls and long-term institutional

care

• Mental Health – services are not integrated with physical health and social care

• Lack of positive risk taking in the current service configuration, risk assessment and planning for people to achieve their goals

Prevention, Primary, Community

• There are limitations in the services offered due to funding and the payment framework and this is driving activity towards hospital care

• Payment model does not incentivise self-care, collaboration or innovation

• Pharmacy, Nursing, Dental and Optometry are under-utilised

• Deskilled workforce in primary care due to secondary care- focused model

• Long-term condition management is typically run in secondary care e.g. Diabetes, where most of the service could be primary care-delivered

• Lack of formal approach to how conditions are managed across care settings

Community, Social Care and External Partners

• 24/7 community nursing not in place

• Services are not optimally commissioned and managed with care providers having short-term contracts and no long-term commitments

• Social Care model is over-reliant on high-cost / dependency residential care

• Limited options for Long-Term Care other than residential care

• Community mental health offering over-subscribed and needs development

• There is a very strong voluntary sector and social care market, but it could be better coordinated and is difficult to navigate, especially in times of crisis

• £18m commissioned services and approved providers, although not through coordinated commissioning

• Duplication of services and back office functions

• Lack of public understanding of services available and signposting to services

• Careers are not adequately supported by the current system as many are supported by the voluntary sector and Parishes

FUTURE CARE

Building on the foundations of P82, the care model has been developed as a clinically and professionally-led model for how health and care services are delivered across all sectors on the Island. The model seeks to move away from the unsustainable institutional-based model into a more modern community-based model, putting patients, their family and home at the centre of care.

The model is based around these components:

1. Person-centred Care
2. Primary and Community Services
3. Specialist Services

Person-centred Care

• A new model for healthcare, focusing on prevention and community partnership

• Ensure care and support are person-centred: personalised, coordinated and empowering

• Develop self-care and patient education programmes to enable people to look after themselves better

• Improve health outcomes by ensuring that care from different providers is not delivered in silos

• Develop partnership of purpose with community sector and improve signposting and coordination  

• Lead in the use of technology to empower people to manage their health and care

Primary and Community Care

• Make full use of breadth and depth of primary care resources including General Practice, Pharmacy, Dental, Ophthalmology

• Support Primary Care to manage long term conditions

• Enhance Primary Care with knowledge transfer and support from specialist services in Secondary Care

• Improve rapid access to diagnostic services and specialist advice and guidance to help people stay within primary care

• Rapid response and reablement as default options - delivered in patients' homes, care homes or hospital

• Positive risk taking; risk assessment and planning for people to achieve their goals

• Person centred planning; maximise independence, confidence and resilience

• Focus on crisis response and home-based reablement / care

• 24/7 Community Nursing will be introduced to ensure that nursing cover supports people at home overnight

• Mental Health crisis prevention services to be established

• Support independence through bespoke care packages that incorporate assistive technology  

• There will be an increase in personal choice and working with external partners to reduce the key pressures that an ageing population presents  

• Increase support to parents/carers

• Government will establish a scalable commissioning model developed in partnership with external providers

• Develop a Partnership of Purpose for wider external provider network to help steer the market where appropriate and support pathways of care

• Establish a care coordination and signposting function to help all navigate the available options

Specialist Hospital Services

• Hospital front door becomes an Emergency Care Centre which incorporates an Urgent Care service, paediatric, mental health and ambulatory assessment

• Mental health acute services provided on the same site as physical hospital services

• Theatre  utilisation  and  flow  will  be  optimised,  with  more  day  surgery  to  reduce demand for inpatient beds

• Hospital will be preserved for hospital care, meaning patients requiring care that can only be delivered in hospital will have more timely access

• Hospital services such as diagnostics and specialist treatments will be sustained

EXAMPLES OF THE JCM IN PRACTICE

The  following  section  highlights  stories from different sections of the care system. (The  names  have  been  changed.)  The services covered are not exclusive, and are often  in  their  infancy,  but  demonstrate alignment to the direction of travel for the care model.

PRIMARY CARE MENTAL HEALTH & SOCIAL PRESCRIBING

Bob said that working with the primary care mental health and social prescribing practitioner was a huge help with managing stress and working through issues that had been holding him back, both professionally and personally, without having to wait several months or longer, which would have taken a massive

toll. He could not thank the service enough for its help and support through some very difficult times and hopes that more people are able to access this fantastic support, which is very much needed in Jersey. Being able to talk to someone face to face and work together on how to manage difficult situations, in a timely manner, has really been incredibly beneficial.

MENTAL HEALTH – COMMUNITY OUTREACH

Home treatment team / admission avoidance / early discharge

Esme is a 42-year-old woman with a long- standing diagnosis of schizophrenia. She has had multiple admissions in the past to Orchard House due to disengagement with services and discontinuation of treatment. Historically Esme's mental state would deteriorate in the community and she would be detained by the police under Article 36 then subsequently be

detained under Article 22 of the Mental Health (Jersey) Law. Historically, it would often take several months for Esme to recover from an acute episode and deterioration in mental health and she would have to be treated against her wishes.

Esme is seen regularly by her community consultant psychiatrist and care co- ordinator. It was noted that Esme was showing signs of deterioration which would normally result in hospital admission. However, before there was further deterioration, she was referred to the newly established Home Treatment Team which immediately began to engage with Esme on a daily basis. They supported her care in the community by assessing and monitoring her mental state and they engaged with her around her medication to check she was taking it properly. The Home Treatment Team

remained actively involved for over three weeks until her mental state stabilised, and her care could be transferred back to her community team. Mental Health services were able to avoid inpatient admission and Esme did not suffer a relapse of her illness.

COMMUNITY RESPIRATORY TEAM

Outreach to community to prevent admissions

David is a patient with End Stage COPD on maximum dose of medications and other non-medical treatments. He lives in a residential care home. In 2019 he had around eight Hospital admissions to the Intensive Care Unit (ICU) with Respiratory Failure Type II and he required non- invasive ventilation. ICU admissions with Respiratory Failure Type II on COPD patients increase the mortality in more than 50% of cases. In 2019, David had an

estimated secondary care cost of around £160k.

David's case was switched to a community model where he came under the caseload of the Respiratory Specialist Nurses Team. A multidisciplinary approach was taken with David and all stakeholders (Home Manager, Social Services, Long- Term Care Nurses, GP, Respiratory Nurse). First-line and second-line responses were provided in the community by a joint team (GP/ Respiratory Nurses / Rapid Response Team).

Since January 2020, David's hospital admissions have been reduced by 100%. Being able to work together and have the resources in the community on how to manage difficult acute exacerbations, in a timely manner, has been incredibly beneficial to David.

RAPID RESPONSE

Service user: When my Doctor told me I was on the verge of going into hospital for my chest infection, I asked if I could have the Rapid Response Team, and within 1 ½ hours from leaving the surgery they were treating me with intravenous antibiotics and they came for five days. They are a lovely team and so friendly - long may this service continue.'

CLOSER TO HOME

Jersey Library Outreach - "Thank you so much for the books you lent my husband – just what he needed. We used to go to the library in town all the time but now I don't drive I find it too difficult to carry the books"

Jersey Sport - "The exercise sessions we have delivered at Communicare have been some of the best that we have been able to deliver. This is due to the help of the staff at Communicare, the opportunity to have a coffee after the session, but most

importantly it has been a welcoming environment. All participants who took part had never been to Communicare before but really enjoyed it and have said they will be bringing a friend next week. There is a much better community feel about the sessions and we believe this will grow considerably in a short space of time."

Social Work - "I have received a referral from Call & Check for a gentleman who requires social care assessment. This was taken at Communicare, which was key as the referral may not have been spotted this early in the person's set of circumstances if services were not available close to his home. This referral will lead to early intervention and prevention work."

"As a result of a social worker being present at Communicare at the same time as Call & Check, networking opportunities have led to an invite for Call & Check to attend the social work team meeting to

provide a presentation to the Adult Social Care Team."

SOCIAL CARE – PERSONAL BUDGETS

Gordon, 54. My mother was already in a care home, and the services my father was getting at home just weren't working. They would come and give him breakfast and lunch, but they were too rushed to talk to him so didn't know if he ever ate it. The microwave meals were piling up and he was living on crisps and biscuits. He was deteriorating and becoming isolated.

So I rang social services and they told me about individual budgets. We wrote a very detailed support plan tailored to his needs and were awarded a budget. This was great because it provided for respite care to enable us to go on looking after my

father. He used to go to my mother's care home for six hours a week, plus some overnights. My father improved physically and used to come out for walks with the family. It was a huge improvement on the previous situation.

SOCIAL CARE - REABLEMENT / FRAILTY

Marjorie received an individualised programme that was cost-saving and allowed her to remain at home. Two months away from her 103rd birthday, after suffering a fall which left Marjorie with a badly injured shoulder and leg, she was admitted to hospital. Following a progressive recovery, it was felt that the best aid towards Marjorie regaining her independence was through the Reablement service.

Over the six-week programme, Marjorie developed the strength and confidence to start caring for herself and was soon able

to walk around the house unaccompanied. Marjorie's recovery didn't come without its challenges. With partial sight and hearing impairments, even the smallest task presented difficulties. Marjorie explained: "A simple thing such as

listening to the carer or hearing the doorbell ring when they arrived was a struggle. It just makes everything that

little bit harder not being able to see and hear, especially when you're as old as me!"

However, Marjorie fought every obstacle thrown her way and nine weeks after her accident she is living at home independently.

Marjorie said: "If it was not for the wonderful people from the Reablement team I would not be back in my own home looking after myself. I felt from the very first day, I knew them. They made me feel so cared for and that it was possible to take my life back into my own hands."

SOCIAL CARE - REABLEMENT / STROKE

Barry was referred to the Reablement Team after suffering a stroke that had debilitated his left-hand side and inflicted memory loss. At the time of the stroke, Barry was supporting his wife who was undergoing treatment after recently discovering she had breast cancer.

Due to his poor mobility and memory loss, Barry was left feeling vulnerable and anxious at the prospect of caring for both his wife and himself. However, with the help of the Reablement team, they were able to assess the level of intervention needed and what equipment Barry required to allow for an easier recovery.

Barry initially received four daily visits and small pieces of equipment such as grab rails, toilet surrounds and a showering stool were put in place to allow more independence with personal tasks. Due to

Barry's memory loss, blister packs were given to ensure that he was taking the correct medication which helped with building the confidence needed to take care of himself.

Over the six weeks, Barry was able to reduce his calls and began to take control of his life. He began Reablement worried that he wouldn't be able to cope with his recovery whilst caring for his wife, but the support offered allowed him to get back on his feet. Barry is now independent and has the confidence that if his wife was to be admitted to hospital, he would be able to manage independently at home.

LONG-TERM CONDITIONS MANAGEMENT E.G. DIABETES

Jo was a regular attender at the specialist diabetes clinic, but also at his GP practice due to other health conditions. In the new integrated system, Jo is supported to manage his own care through better education programmes and technology. He checks in with his GP for his annual checks at the same time as his other appointments. The GP occasionally checks in with the Diabetes centre via the same IT system if there is a specialist problem to discuss. Jo is now making good progress through improved ownership of his lifestyle.

Barbara, 46, had a sore shoulder that for months had been deteriorating. Rather than having to wait for a specialist referral to secondary care, she accessed her local primary care physiotherapy service after a brief consultation with her GP. She is now on the road to recovery.

HOW CAN WE KNOW IT WILL WORK?

A key commitment to Islanders was that this model would be externally stress tested' to provide an objective assessment of the validity, feasibility and deliverability of the model with a focus on:

• The proposed model's attributes and features, particularly those that represent changes from current service model delivery against an agreed assessment framework

• Interdependencies between areas of care

• Enablers that will support the delivery of care.

The HealthCare team at PWC were engaged to help review / stress test / develop the model from an independent viewpoint (the Jersey Care Model Review). A programme of review was established which saw each of the nine main workstreams comprehensively reviewed with relevant stakeholders (internal and external) from across the system. A financial analysis was also conducted to establish the costs and benefits of the model. The report[1] of this is appended to this report, as is the strategic outline business case[2] which sets out the investment requirements and benefits profile for the model.

Following completion of the Jersey Care Model Review, an addendum to the Review has been inserted at the request of the Council of Ministers. This request asked for updates to provide revised implementation and financial information following further assessment of the JCM considering COVID-19 and associated impacts on deliverability.

PWC METHODOLOGY AND APPROACH

An independent review was completed over an 11-week period by the PWC Healthcare Team.

The findings outlined in the PWC report were developed through adopting an iterative, clinically-led approach. Working with key clinical stakeholders in Jersey, a five-stage approach was adopted (see Figure 1 below).

To structure the analysis, an assessment framework was applied to the model (see page 20, JCM Review) which was agreed with the respective groups that provided governance over the JCM review.

Over 150 stakeholders were engaged across the Jersey health and community care system as part of the review.

Whilst an independent review, it was imperative to have strong clinical engagement to provide context, feedback and oversight of the programme, which is outlined in Figure 2. Detail on the Clinical Engagement performed for the review can be found in Appendix 8 of the JCM Review.

FINDINGS OF THE JCM REVIEW[1]

Overarching model and workstreams

• The review found that overall the model is in line with good practice for integrated care and when implemented will enhance quality, safe and timely care; benefits can start to be realised immediately

• Some areas of the JCM are misaligned with its ambition and require further work and detail

JCM enablers

• The model is financially sustainable and will not cost more to the service users if resource allocation, funding models and commissioning arrangements are amended

• Feasibility of the JCM rests on an appropriate and enough workforce and digital capabilities

Further JCM enhancements  

• The shift to preventative, service user-centred care and self-care is fundamental to JCM; however, how this will be systemically delivered is still unclear

• To realise real benefit, a Population Health Management[2] approach should be adopted

• To be a leading model globally, the JCM will need to expand the care model beyond traditional settings and workforce

Assumptions and limitations

• The level of alignment and commitment across partners will be imperative

• The JCM will only be achieved through a decentralised care model

Public Perception[3]

• The JCM assumes that all Islanders will be supportive of service changes; this is broadly in line with the findings from the review

• Through the extensive public consultation meetings in Parishes, it is clear that the health care system in Jersey is important to Islanders. While there is a strong

viewpoint provided, overall, there is recognition from Islanders that a change is required, and a health and care system that is integrated and sustainable is important and needed for Jersey.

PWC's view of the top ten benefits of the JCM[4]:

• Supporting people to live independently at home by offering integrated, community services

• Developing and strengthening partnerships between primary and secondary care with external partners to prevent duplication of services. Additionally, developing partnerships off-island to provide joint specialist services

• Innovative care delivery through digital solutions and services

• Repurposing existing estates and forming strategic partnerships with parishes

• Streamlining current pathways and processes, particularly in relation to referral management for long-term conditions

• Removing barriers to access for vulnerable service users through re-modelling funding structure

• Reducing and delaying people's need for care, through investment in preventative services

• Developing new ways of providing services, for example, development of an Urgent Care Centre, and where possible, exploring the expansion of existing services

• Expanding existing crisis response services to lower avoidable inpatient admissions

• Improving children's health through several initiatives supported by Public Health

BENEFITS / COSTS AS VALIDATED BY PWC

As validated by PWC, the JCM is financially sustainable[5] and will not cost more to the service users. This is provided that resource allocation, funding models and commissioning arrangements are amended. After investments, the JCM is forecast to avoid £23m per year by 2036 of the expected expenditure growth for Jersey's health and care system.

In order to deliver the JCM and realise the expected benefits, investment of £28.1m over this government plan (2021-23) is required, before the model could deliver a net financial benefit from 2025. £17m of non-recurrent investment over a five-year period is required in order to deliver the savings (included within the £28.1m).

Non-recurrent investment requirement

Non-recurrent investment is expected to fall across two main categories:

• Programme costs: These are the costs associated with the transformation programme required to deliver the JCM. It is expected this programme would operate over a five-year period. The costs associated with this would cover PMO support, organisational development support, communications support and digital transformation subject matter expert(s).

• Digital non-recurrent investment: The JCM describes the requirement for several new digital tools for use across the health and care system. These include investment required for integrated care records and Jersey care record, core record systems, hub and micro services, and analytics. These investments have been split between non-recurrent revenue and capital expenditure lines.

In addition to this, further non-recurrent expenditure has also been assumed to provide contingency for the programme.

Further details on the breakdown of this non-recurrent investment requirement can be found in sections 4.2.3 and 4.3.4 of the JCM Strategic Outline Business Case[6].

Recurrent investment requirement

In addition to the non-recurrent investment, the JCM requires the implementation of a number of new services and the expansion of some existing out of hospital services. Over the 16 years to 2036, these have been estimated to cost a total of £679m.

The new services required through the JCM primarily relate to out of hospital provision of health and care services that avoid hospital care (inpatient or outpatient) or long-term care placements.

These have been assumed to ramp up from 2021 and, by 2036, they will cost £67m per year. An element of double running has been assumed between the new services coming online and benefits being achieved. In particular, unless otherwise identified through the implementation plan, it has been assumed that changes will take 12 months from the implementation of the new service before the impacts of the JCM are fully delivered (leading to an initial net recurrent investment in 2021 to 2024).

Further details on this recurrent investment requirement can be found in sections 4.2.3 and 4.3.3 of the JCM Strategic Outline Business Case.

Do nothing' scenario

In the do nothing' scenario, where provision remains predominantly provided by the acute sector, but demand and activity increase due to a growing and ageing population, the service will face a significant affordability challenge driven by an increase in activity. In the do nothing' scenario, there is a predicted growth in cost across the system of 112%. This would see the total expenditure on health and care services rise from £378m to £716m by 2036.

Population growth and demand and capacity

The do nothing' growth assumptions are based on data from the latest demographic growth scenarios provided by Statistics Jersey. Several assumptions have been made in modelling population change, demographic change and associated demand and capacity. See the strategic Outline Business Case, Financial Case for full details of these assumptions.

In a do nothing' scenario, there is projected to be increased demand across all areas, with up to a 35% increase in activity in non-elective in-hospital care by 2036.

Do something' scenario

Analysis of the financial benefits for the do something' case suggest that there will be a do something' gross impact of £90m per annum by 2036. When accounting for the recurrent costs of re-provision of new services, net cost reductions of around £23m per annum are expected by 2036. See the JCM Strategic Outline Business Case section 4.3.4 for full details of these assumptions.

In total, the JCM is forecast to avoid just under £23m per annum of expenditure growth for the health and care system by 2036.

For each of the changes proposed in the JCM, PWC estimated how patient flows will be impacted and then modelled an appropriate change in forecast expenditure. This includes both areas where activity will reduce (i.e. removing patients from in hospital settings) and where they will increase (i.e. provision of new services to enable the change).

Through implementing the changes proposed in the JCM, the financial sustainability of Jersey's health and care system will be significantly improved.

In addition to the non-recurrent investment, the JCM requires the implementation of several new services and expansion of some existing out of hospital services. Over the 16 years to 2036, these have been estimated to cost a total of £679m.

As a result of these investments, over 16 years, the JCM is forecast to avoid a total of £874m in expenditure growth compared to the do nothing' scenario (where no changes are made to the health and care system). Net of the recurrent investment requirement, there is a total forecast reduction in expenditure growth of £195m compared to the do nothing' scenario, which falls to an impact of £178m once non-recurrent investment has also been removed.

The JCM will avoid expenditure growth and particularly improve the financial position of the Long-Term Care fund.

As a result of the JCM, sustainability of Jersey's health and care system is forecast to significantly improve. From 2025 onwards, the savings associated with the JCM start to exceed the investments.

Figure 2: Do something' net benefits from delivery of the JCM

LONGER TERM FUNDING & BUDGET STRUCTURES

To integrate the health and social care system, a different approach will be needed to funding and financial management across the system. A one system, one budget approach will need to be taken to truly integrate services. Currently, there are several funding sources e.g. from tax, social security, user payments, and insurance; these often create inefficiencies in the system. A full review of the system financial sources, process and structures will be required over the next four years to create a sustainable, efficient model for health and care on the Island.

COVID – IMPACT AND LATEST POSITION WITH GENERAL PRACTICE

Health and Community Services and General Practice, via the Primary Care Body (PCB), have been in dialogue about the future funding model for general practice. Pre-COVID, a set of sessions was held to evaluate potential options to support various projects e.g. P125/2020 Access for the financially vulnerable to GPs. PWC also helped to assess and work up cost models for various options of payment and incentivisation, as presented in the JCM Business Case. The PCB has also submitted proposals for a hybrid funding model post-COVID for the longer term which has the broad support of General Practice.

During the pandemic in early 2020, HCS and the PCB worked together to ensure the continuity of general practice during this period. A temporary employment contract was put in place for four months, with GPs directly employed by HCS during that time. That contract ended in August 2020, with practices returning to their usual operations at that time.

Exploratory work was undertaken towards the end of the contract period looking at options for potentially extending the contract, or putting in place a new version, to accelerate ambitions for changing the model on a more permanent basis. The review determined that further work and analysis was required in order to negotiate the right arrangement for all parties and that it should not be rushed.

All parties are committed to developing a funding model via the JCM that helps take the health and care system forwards. General Practice through the PCB continues to engage with the Government of Jersey to explore care models in conjunction with funding models consistent with the principles of the Jersey Care Model. The PCB supports a transition to an evolved care model and looks forward to continued engagement along with Health, CLS and other stakeholders.

IMPLEMENTATION

Following the review of the JCM, a multi-year implementation plan has been developed with key projects prioritised in tranches[1].

Taking on board the finding of the JCM review, and through internal planning, it is been determined that the implementation of the JCM will be completed in three tranches. The emphasis of the first tranche will be on detailed planning, particularly around workforce and change management, to be able to support our health and care professionals to deliver in the new model, establishing the necessary foundations to deliver on the new model, and driving care delivery through enhancing intermediate care. Implementation will need to be phased, to be able to shift to the new model, while being responsive to any immediate needs on the system, including COVID-19.

In developing a realistic and achievable implementation plan, the deliverability of the JCM was reviewed. Considering the emerging challenges the Island is facing post-COVID-19, the phasing of the programme has been amended to allow stabilisation of the platform within Jersey with the roll-out of the programme phased in three tranches outlined in Figure 3.

Figure 3: JCM prioritisation framework for implementation

These tranches are still in line with the key areas as identified within the PWC review. An initial summary of key areas of focus is outlined in Table 5.3 in the JCM Business Case[1]. As noted, the areas of focus upfront are targeted on detailed planning to establish the foundations of the JCM, and clear communication of the programme progress and changes to Islanders and staff.

JCM IMPLEMENTATION GOVERNANCE[1]

Governance has been established to provide oversight (including clinical oversight) over the JCM review and this will continue through implementation.

Three key oversight groups were established as part of the JCM Review programme to provide input, review, challenge and oversight:

• Integrated Care System Leadership Team (formerly the JCM Steering Committee): formed to provide strategic leadership, direction and overall decision-making capability for the JCM review.

• Clinical and Professional Senate: provided strategic oversight and recommendations on the outputs of the JCM review. It is proposed that the Senate will continue to make decisions regarding the implementation and delivery of the JCM beyond the completion of the review.

• Technical Group: created to oversee data analytics, modelling and provide decision- making capability in relation to quantitative analysis.

These groups will continue as part of the implementation of the programme.

External assurance arrangements will also be established during programme mobilisation.

PWC FINDINGS OF FURTHER OPPORTUNITIES IDENTIFIED IN STRESS TEST

PWC identified several areas where the Jersey Care Model could potentially be enhanced[1]:

The prevention agenda should not be limited to the list provided. There are other opportunities for preventative measures throughout workstreams, for example, in Women's Health, Children's Health and Mental Health. Working with Public Health will support benefits realisation, whilst helping deliver on government policy.

Embedding preventative health in the future JCM will prove challenging as it will require significant financial investment. Despite these high costs, preventative health is widely regarded as a cost-effective means of improving population health.

Jersey could consider an alternative payment mechanism to support the shift to preventative care. If Jersey was to move to a different system in primary care, including for community pharmacy, this could incentivise prevention, in turn keeping healthcare costs down and supporting the integration of care.

Building on the prevention agenda, there is further opportunity for the JCM to achieve real gains through a focus on driving service user-centred and led care. This is encouraged by the ageing population and increasing prevalence of long-term conditions.

Digitising the system can help realise the full benefit of self-care in Jersey. In health and care systems where self-care is prominent, digital front doors (i.e. an online point of access for information and, signposting and possibly referral) help redirect service users who would traditionally present to primary or secondary care services to self-care models. For Jersey, a digital front door could not only reduce unnecessary attendances but also address the issues regarding staffing.

To realise the full benefit of the JCM, a Population Health Management (PHM) approach should be adopted

PHM is an approach to using data from across the health and care system to segment the population according to their risk profile, and to proactively identify where interventions may prevent that level of risk escalating. Rather than taking a disease-focused view (e.g. identifying those with diabetes in the over-65 age group), PHM allows a more nuanced view of risk as it considers a wider selection of data points.

Jersey has made some progress on moving towards a PHM-enabled model, although there is more to be done. Jersey can make real progress with PHM, due to the way in which data

sets are collected and managed in Jersey already. The Jersey health system is more of a closed system' than many NHS systems as there is less patient flow across boundaries of the health system, except for some specialised services. In addition, the implementation of the JCM will create a longitudinal data set (i.e. a set of data/records over time), which would provide a useful foundation for population health analytics.

To be a leading model globally, the JCM will need to expand the care model beyond traditional settings and workforce. Leading integrated models extend the delivery of health beyond social care to incorporate non-traditional healthcare providers

While advanced systems aim to integrate their health and social care services, leading systems look to integrate these more traditional models with the wider components in their system, including schools and government agencies. This type of whole system integration can impact on broader population wellbeing.

While the JCM identifies the importance of pharmacies, dental and ophthalmology services in the Island's future integrated model, there are numerous other services that could be considered to achieve leading edge good practice. These services are accessed across the life of a service user from infancy to older age and are reflected in all aspects of living within a society. These include:

• Schools – can improve health literacy, create healthy habits and lifestyles

• Businesses – to provide mental and physical health checks and programmes, promote healthy alternatives

• Clubs and societies – to promote health discussions, encourage social interaction and mental health

• Government agencies – to provide incentives for healthy living, including financial benefits for healthy lifestyles

• Urban planning – redesigning public spaces and amenities, as well as planned housing to promote an increase in healthy lifestyles.

In addition, the provision of health and care does not always need to involve trained professionals.

The JCM will require a workforce different to that currently seen in Jersey. The model will need to look to an alternative workforce that expands from clinical to a wider range of staffing groups. This would not necessarily mean a substitution of the workforce, but additional service users who can enhance a culture of health and wellbeing on the Island.

FREQUENTLY ASKED QUESTIONS

It is important to highlight what the Jersey Care Model is not proposing in order to avoid misconceptions of the changes being proposed.

What the JCM is not:

1. The JCM is not nationalisation of GP and community services. GPs play an important role in the delivery of healthcare provision within the Island and it is accepted that many of the valued system benefits of the GP service must be retained in future care models, such as continuity of care for patients by GPs and direct access in a timely fashion.

Whilst the JCM seeks to empower and equip GPs to support additional services in the community, this cannot be undertaken to the detriment of ease of access and continuity in care and any proposed changes will require negotiation with GP partners.

There is commitment to ensure, however, that access is available to all, and in particular, vulnerable persons.

Community provision through the many third-sector organisations on the Island would continue under the Jersey Care Model with longer term contracts in place and more clarity in service specification.

2. The JCM does not replicate the NHS and it is recognised that health and care services are different within Jersey and must be tailored to the requirements of Jersey. It must be borne in mind that most of our health and care professional workforce are trained and educated within the UK healthcare system, but this does not mean the NHS approach is required.

The UK NHS system provides nationalised Hospital, GP, Community & Primary care services that are Government-led under a constitution of care. Under the JCM proposals, the Jersey Government retains the provision of core Hospital, Community, Mental Health and Social Care services. GPs, community pharmacy, dentistry and ophthalmologists remain independent service providers and community organisations such as Family Nursing and Homecare, Jersey Hospice Care, Mind

Jersey and others remain sovereign bodies that are commissioned by Government to provide key services.

Pathways proposed under the JCM have and will continue to be developed with all system partners.

3. The JCM has an important role with the development of the new Hospital, but it is important to note distinct differences between the two initiatives.

The specification of services for the new Hospital in Jersey has been developed by clinicians through the clinical brief process of the Our Hospital Programme. We have committed that all the current services provided at Jersey General Hospital will be provided in the new Hospital facility and the process for designing and planning clinical functions and adjacencies sits outside the remit of the JCM.

The JCM has explored pathways that transition in and out of hospital and it is in this area where there is connectivity between the two programmes. It is important to note the JCM is a transformation programme and that regardless of the Our Hospital programme, the health and care system would still be required to implement many of the proposed changes in order to meet the demographic challenges outlined.

The JCM seeks to co-ordinate the Island response to those challenges and this will enhance the function of the Hospital, but it will not determine that function. We anticipate benefits such as robust out of hospital care will impact upon patient flow through the Hospital, but these initiatives would be pursued with or without the JCM transformation programme.

4. The JCM is not seeking to stop Residential and Nursing Care provision on the Island. Whilst the JCM has identified heavy reliance on this sector of care within Jersey, it does not seek to prevent Residential and Nursing Care being available for Islanders who wish to access it. The JCM seeks to provide Islanders with a choice of future care both at home and within other longer-term care settings such as care homes.

The COVID-19 pandemic has outlined how important this part of our health and care system is and how vital it is to sustain these services. In addition, it is anticipated new care provision being provided within Jersey supporting people with Dementia

such as Extra Care village' concepts and specialist services such as Learning Disabilities.

5. The JCM is not a financial strategy. The model was designed by clinicians and health professionals and the financial impact and benefits realisation of the JCM has been determined through internal and external review. Best practice in high quality care delivery is evidenced to often be more financially efficient and this approach provides an opportunity to re-purpose workforce and investment across the system of healthcare.

APPEDICIES

Appendix 1 – JCM Briefing Paper (pp.38-169)

Appendix 2 – JCM Review Paper (pp.170-355)

Appendix 3 - JCM Strategic Business Case 2020 (pp. 356-493)

END

APPENDIX 1

APPENDIX 1

HEALTH AND COMMUNITY SERVICES

JERSEY CARE MODEL

Produced by Jersey Health and Community Services, October 2019.  V1.1

CONTENTS

Version History ....................................................................................................................................................... 3 Authors ................................................................................................................................................................... 4 Definitions / glossary .............................................................................................................................................. 5

Health and Community Services Ambition and Vision ........................................................................................... 6 Our Proposed Care Model ...................................................................................................................................... 8 Work stream Details ............................................................................................................................................. 17

Prevention & Primary Care ............................................................................................................................... 18 Intermediate Care............................................................................................................................................. 22 Secondary Care ................................................................................................................................................. 25 Mental Health ................................................................................................................................................... 30 Childrens' Health .............................................................................................................................................. 35 Adults Social Care ............................................................................................................................................. 38 External Partners .............................................................................................................................................. 40

Appendices ........................................................................................................................................................... 47

Primary Care Appendices ................................................................................................................................. 47 Prevention & Primary Care Appendix A: The Common Strategic Policy re Primary and Prevention ........... 47 Prevention & Primary Care Appendix B: Definitions .................................................................................... 47 Prevention & Primary Care Appendix C: Population demographics and multi-morbidity projections ........ 48 Prevention & Primary Care Appendix D: Long-term Conditions................................................................... 52 Prevention & Primary Care Appendix E: Strategic Aims – more details ....................................................... 52 Prevention & Primary Care Appendix F: Enabling the Strategy .................................................................... 53 Prevention & Primary Care Appendix G: Notes on Intermediate Care ......................................................... 53 Prevention & Primary Care Appendix H: Current Funding Sources .............................................................. 54 Prevention & Primary Care Appendix I: The Future of Funding for Prevention and Primary Care .............. 55 Prevention & Primary care Appendix J: Primary Care pharmacists - example of value opportunity ........... 58 Intermediate Care............................................................................................................................................. 60

Intermediate Care Appendix A: Intermediate Care Service Definition - High Level .................................... 60 Secondary Care Appendices ............................................................................................................................. 64 Secondary Care Appendix A: Emergency Care ............................................................................................. 64 Secondary Care Appendix B: Bed Base ......................................................................................................... 68 Secondary Care Appendix C: Planned / Scheduled Care .............................................................................. 71 Secondary Care Appendix D: Day Surgery Theatre Utilisation ..................................................................... 72 Secondary Care Appendix E: Step Down Care & Intermediate Care ............................................................ 75 Secondary Care Appendix F: Hospital Service Analysis................................................................................. 75 Mental Health Appendices ............................................................................................................................... 84

Mental Health Appendix A: Data Analysis .................................................................................................... 84 Mental Health Appendix B: Community Mental Health Team Caseload / Contacts .................................... 86 Mental Health Appendix C: Government Plan 2020-2023 Business Cases................................................... 88 External Partners Appendices............................................................................................................................... 91 External Partners Appendix A: Introduction / Background / Context Further Detail ................................... 91

External Partners Appendix B: Framework for partnerships with the Voluntary Sector, Private Sector and Social Enterprises .......................................................................................................................................... 95

External Partners Appendix C: Commissioning Framework Outline........................................................... 100 Health Systems Comparison Report ................................................................................................................... 113

VERSION HISTORY

AUTHORS

DEFINITIONS / GLOSSARY

A smaller number of hospitals in the UK provide what is called tertiary care', which means the third level of care. This is where hospitals, such as Great Ormond Street for children, and Southampton Neurological Centre, look after patients sent to them by other hospitals for highly specialised care. Jersey sends patients typically to the UK for most tertiary care.

Social Care  Care across the Island provided by either Government of Jersey,

commissioned charities or private companies for those Islanders, who need additional support and assistance in order to live comfortably, for example help with washing or eating, respite services, and End of life Care.

HEALTH AND COMMUNITY SERVICES AMBITION AND VISION

Our ambition is aligned to the Government of Jersey strategic priority (Common Strategic Policy 2019) to improve Islanders wellbeing and Mental and Physical Health.

To achieve our ambition, we will

• Put Children First

• Support Islanders to prevent ill-health and adopt self-care as part of our shared commitment with Islanders to maintaining a healthy lifestyle

• Ensure services provided by HCS and external partners are: high quality, efficient and effective, working to professional standards shared by professionals and volunteers across the delivery of Health and Social care

• Harness the experience, ambitions and insights of professionals and volunteers involved in delivering care and  our  service  users  when  planning  and  organising  services  around  our  service  user's  needs  and circumstances

• Make the best use of resources available for the development and delivery of publicly funded services and help to support service users to secure Value for Money (VFM) when paying for services

• Ensure HCS is business like in the ways it works, encouraging staff to exhibit the values and behaviours that underpin the Team Jersey culture.

Health and Community Services Vision

Our vision for Health and Community Services is to create a healthy Island with safe, high quality, outcome focussed, affordable care that is accessible when and where our service users need it.

Building on our strengths

Jersey has many strengths across our health economy and we need to build on them when designing change.  Among our strengths are:  

• Our committed workforce  

• The breadth and depth of our services, despite the small size of our population  

• Timeliness of services compared with many jurisdictions  

• Our Parish system and wider community assets  

• Our carers in the community  

• Access to investment in health remains a strong political priority  

• Our long-term care benefit scheme

• Our resilient Primary Care and the prevalence of GP's in the Island

• The unique blend of Primary and Secondary Care

• A strong culture of voluntary work

OUR PROPOSED CARE MODEL

To deliver truly patient focussed, outcome-based care, a OneIsland, OneGovernment approach, we need a clear idea of the building blocks integral to meeting Jersey's overall Health and Care system needs.

At the centre of the model are the core provisions included in any Health and Care system:

• Prevention and Self-Care – includes the actions that people take to look after, treat and manage their own health, either independently or with the support of the Health and Care system

• Primary Care – Usually the first point of contact for people in need of Health and Care services e.g. GP's, Nurses, Dentists, Pharmacists and others

• Intermediate Care – Services that provide support for a short time to help people prevent problems from getting worse, recover from an episode of care or increase independence

• Secondary Care – Specialist treatment for a defined period of time for a more acute serious illness, injury, mental health crisis or other health condition

• Tertiary Care – Highly specialised treatment which for Jersey is provided off Island

The Care Model identifies a number of principles to improve our Health and Care services:

• There is no health without Mental Health. Mental Health is just as important as Physical Health

• We must support people of all ages, from family planning to bereavement services

• We must treat all people equally and ensure equal access to services regardless of Gender, identified Gender, Sexuality, identified Sexuality, Nationality, Ethic Origin, Age, Disability, Language or Presenting Illness

• Social Care and Safeguarding services must underpin our Health and Community Services

• Community services, education, employment and housing are fundamental as  it isn't just Health services that keep people healthy

• Our services must be built on platforms that enable efficient working and evidence-based decision making, supported by technology and information

• Our services must be built on robust governance and risk management frameworks

• Our services must involve the voices of our service users

• There must be smooth transitions and hand offs when service users transition from one type of care to another

• There  must  be  smooth  interaction  in  the  way  each  component  of  the  health  and  care  system communicates with each other and how we communicate with our service users

• Services must be designed and available according to need

• We must work within available budgets and ensure the delivery of Value for Money, outcome-based

care.  

JERSEY CARE MODEL - CURRENT STATE ASSESSMENT Secondary Care Focused Model

• The Hospital is the centre of care for the island. People are institutionalised via provision of central services

• ED attendances – we see a high rate of low acuity cases – also evidenced by our low conversion rate from ED to main hospital

• We are currently underutilising our theatres both in terms of scheduling and use of day case theatre

• Rehabilitation / length of stay – we have a long length of stay in rehab and high flow rate into Long Term Care (residential)

• Out patients - new to follow up ratio is high in comparison to benchmarks – suggesting that Secondary Care is not discharging back into primary care

• Rapid response could be optimised to keep people out of hospital – very limited service currently

• Reablement services are limited and not standard to assist people staying or going home

• Our system is too reliant on beds, particularly for older demographic care

• Mental Health – services are not integrated with physical health

Intermediate and Ambulatory Care

• Rapid response and reablement not delivered consistently and to their full potential to help people remain at home

• Lack of positive risk taking in the current service configuration; risk assessment and planning for people to achieve their goals

• The current teams are not configured to manage higher risk patients due to lack of 24/7 cover and skills mix

• We have an institutionalised model where patients are brought in to hospital as the default option

• Lack of 24/7 Community Nursing means that there is no nursing cover to support people at home overnight

• Mental Health Crisis prevention service requires development to support increased demand

Prevention, Primary, Community

• There are limitations in the services offered due to funding and payment framework

• Payment model does not incentivise self-care, collaboration or innovation

• Pharmacy, Nursing, Dental and Optometry under-utilised and can't be funded

• Deskilled workforce in primary care due to secondary care focused model

• Long term condition management is typically run in secondary care, e.g. Diabetes

• Lack of formal approach to how conditions are managed across care settings

Community Care  

• 24/7 community nursing not in place  

• Services are not optimally commissioned and managed  

• Social Care model is over-reliant on high cost / dependency residential care  

• Limited options for Long Term Care other than residential care  

• Community mental health offering over-subscribed and needs development  

Direct access services

• Primary care services such as Pharmacy, Dental and Ophthalmology are not empowered to play as big a role as they could

• Funding mechanisms not in place to allow extended services to be provided

• Most services are accessed / paid for directly by the public, e.g. Dental and Ophthalmology

• Technology and information sharing are sometimes a barrier to joined up service provision

Social Care and External Partners

• We have a very strong voluntary sector and social care market, but could be better coordinated and difficult to navigate, especially in times of crisis

• Over £80m is raised annually, 1 in 8 adults on the island are volunteering

• £18m commissioned services and approved providers, although not through coordinated commissioning

• Duplication of services and back office functions

• Lack of understanding and signposting of all services

• Carers are not adequately supported by the current system as many are supported by the voluntary sector and Parishes

JERSEY CARE MODEL – PROPOSED STATE Jersey Care Model

Building on the foundations of P82, we have developed a clinically led model for how health and care services are  delivered  across  all  sectors  on  the  island.  The  model  seeks  to  move  away  from  the  unsustainable institutional-based model into a more modern community-based model; putting people, their family and home at the centre.

The model is based around these components:

1. Person-centred Care
2. Primary and Community Services
3. Specialist Services

Person-centred Care

• A new model for healthcare, focusing on prevention and community partnership

• We will ensure care and support are person-centred: personalised, coordinated and empowering

• Develop self-care and patient education programmes to enable people to look after themselves better

• Improve health outcomes by ensuring that care from different providers is not delivered in silos  

• Develop partnership of purpose with community sector and improve signposting and coordination  

• We will lead in the use of technology to empower people to manage their health and care  

Primary and Community Care

Primary Care

• Make full use of breadth and depth of primary care resources including General Practice, Pharmacy, Dental, Ophthalmology

• Support Primary Care to manage long term conditions

• Upskill Primary Care with knowledge transfer and support from specialist services in Secondary Care

• Access to diagnostics and specialist advice and guidance

Intermediate and Ambulatory Care

• Rapid response and reablement as default options - delivered in patients' homes, care homes or hospital

• Positive risk taking; risk assessment and planning for people to achieve their goals

• Person centred planning; maximise independence, confidence and resilience

• Focus on crisis response and home base reablement / care

• 24/7 Community Nursing will be introduced to ensure that nursing cover supports people at home overnight

• Mental Health crisis prevention

Social Care and External Partners  

• Support independence through bespoke care packages that incorporate assistive technology  

• There will be an increase in personal choice and working with external partners to reduce the key  pressures that an ageing population presents  

• Increased support to the parent/carer forum  

• Scalable commissioning model developed in partnership with external providers  

• Partnership of Purpose for wider external provider network  

• Care coordination and signposting function to help all navigate the available options  

Specialist Services

• Front door becomes an Emergency Care Centre which incorporates an Urgent Care service, paediatric, mental health and ambulatory assessment.  

• Mental health acute services provided on same campus as hospital

• Optimise theatres utilization and flow, more day surgery to reduce demand for inpatient beds

• Rehab – make better use of community, improve access to social care

• Partnership model with primary care for Long Term Conditions, with services provided out of the hospital

• Tertiary care will remain but increased opportunity for repatriation and closer working with Guernsey. We think there is a strong commercial opportunity here.

KEY DIFFERENCES

• The Hospital may be circa 200 beds which is 80 less beds (subject to detailed validation) than the previous FH Plan. We will see greater activity in the community, building on the closer to home' initiative

• The Hospital will focus on Acute treatment and pathways, ensuring diagnostic, ambulatory, day case and intervention focussed services are prioritised. Critical and Specialist care areas including Special Care Baby Unit (SCBU) and Maternity will be in place

• No Westaway Court concept - Long term conditions will be more managed in Primary Care. This approach will replace traditional outpatient services. Up to 40,000 contacts have already been identified through Top 5 speciality analysis (Diabetes, Dermatology, Cardio-Respiratory etc)

• The front door of the Hospital will be smaller (Acute & Emergency Floor model) with a co-located Urgent Treatment Centre hosted by HCS but connected to the Primary Care system. A high proportion of ED activity can be diverted to the UTC (circa 30,000) patient episodes

• We will see a shift in settings of care for our workforce within a virtual hub across many professions with Secondary Sare Dr's providing specialist advice and guidance to GP's who are able to work to the top of their clinical licence

• Mental Health services will be co-located to the new Hospital and focus on crisis prevention and community intervention

• The Social Care Market Strategy will shape the sector into an independence focussed model building on care at home shifting away from institutional residential and nursing care. Reablement will be a default offer before long term care is provided

• There will be a more comprehensive Community Service offer which will run 7 days a week with enhanced intermediate care that is part of a Community Independence Service incorporating Frailty

• We will focus on Connecting Care for Children by enhancing the community and preventative offer which is aligned to the CYPES strategy

• Tertiary pathways will be strengthened but we will aim to repatriate activity where possible (bariatrics and cancer care in particular) through closer working with Guernsey

• Services like Drugs and Alcohol can be provided through external partners

• The prevention agenda will have greater focus for our service strategies away from Secondary Care and into Primary, Prevention and Intermediate Care which will be our biggest Care Group

Which services could transfer out to community?

• Long term conditions: Obesity, Asthma, Diabetes, Renal, Heart Diseases, COPD, End of Life Care

• Community Mental Health services, e.g. Listening Lounge

• Paediatric consultations

• Drugs and Alcohol  

• Frailty  

• Rehabilitation  

• Physiotherapy  

• Dermatology  

• Dressing clinics  

• Midwife lead maternity services  

• Build on Care Closer to Home initiative around community services provision and signposting  

HOW WILL WE MAKE THIS HAPPEN?

A multi-year programme of work will be required to transform services from secondary focussed services to community provision. Services must be transitioned prior to the new hospital facility being available in order to ensure that the model can accommodate the size / shape and function of the new hospital. Key areas for development are:

• A Commissioning Framework for Primary Care and external partners to support the shift in activity – The HIF needs to be re-purposed.

• A workforce strategy that shifts settings of care for key roles

• A profoundly revised provision offers in the Community

• Mental health will need greater investment as identified in the Government Plan – Parity of Esteem for the future

• Social Care will require investment to deliver a revised Market Strategy and Personalisation

• A Partnership of Purpose with external partners is required to coordinate partners

• The Jersey Care Model strategy and Future Hospital must be digitally enabled beyond previous ambition

• Transparency re commercial strategy for secondary care (Public v Private)

• Revised contractual framework for Tertiary Care

• A cross-government prevention initiative is required

• Access for vulnerable groups, children and free dental care

• Culture and Risk tolerance will need to be tackled

HCS ORGANISATIONAL STRUCTURE

Our Government structure for the overall Jersey Health and Care system is built around five groups with four cross cutting services (Figure 1).

Figure 1: Jersey Health and Community Services Care Model Structure  

The new organisation design will support delivery of the Jersey Care Model via focussed care groups which are clinically-led. The new structure also enables:

• Engagement with our patients and service users to ensure the Islands Health and Care system meets their needs and is transparent in enacting the delivery of care that is Safe, Sustainable, Measurable and Value for Money

• Engagement with clinical and non-clinical staff across HCS

• Engagement and collaboration with partner organisations, Primary Care and the Voluntary Sector to ensure our health and care system meets the current and future needs of our island

• Transparency and efficiency in Risk Management and Governance structures with clear accountability

• A modernisation function that will bring together transformation and digital teams across organisations to support and deliver technological change across the Island Health economy.

WORK STREAM DETAILS

The following sections outline the proposed direction of travel for each main work stream of the Jersey Care Model. They present an overview of our current state and highlight opportunities to develop our model of care in order to support the current and anticipated needs of islanders and to support the requirements analysis for Our Hospital. Consideration has been given to: existing strategies, analysis of activity, a review of delivery against strategy, and opportunities to deliver services in a different way to ensure that we have a truly integrated healthcare service across Jersey.

Work streams:

• Prevention & Primary Care

• Intermediate Care

• Secondary Care

• Mental Health

• Children's Health

• Adults Social Care

• External Partners

PREVENTION & PRIMARY CARE

PREVENTION & PRIMARY CARE INTRODUCTION

Our Government has set out the priorities for all Islanders in the 2018 Common Strategic Policy (CSP) which sets the strategic intent around putting children first, improving wellbeing, both mental and physical health, reducing income inequality and improving the standard of living [1]. Just one extract states;

"While prevention is key, mental and physical health and care services must be fit for purpose, support equitable access and be more integrated around the needs of Islanders. Care must be provided when and where it is needed most, and closer to people's homes. To do this, we must evolve our health and care system to meet patients' needs, particularly as more Islanders live longer. This will include testing new approaches to the delivery of primary health care, with more support within the community and Parishes, through multidisciplinary teams, community hubs, and excellent acute care within a new hospital."

The CSP states that in order to achieve our desired outcomes, we shall utilise the system of Primary Care;

1. Actively engage GPs and other health professionals in developing and testing new models of health care delivery.
2. Improve access for vulnerable people, including children and an aging population, to all primary care services, including dentistry, and make it easier and more affordable to use.
3. Create the conditions, which, over the long term, will reduce the most common diseases and preventable death, supporting Islanders to live healthier, active, longer lives.

Furthermore, the shared vision for a healthy Island delivered in most cases in our community mirrors the vision of the World Health Organisation (WHO). Primary Care in Jersey consists of general practice services, community pharmacy, dentistry and optometry. Primary Care plays a crucial role in delivering core health care services whilst having responsibility for referrals to help patients gain access to a large range of other healthcare providers.

"Primary Health Care (PHC) is a whole-of-society approach to health that aims equitably to maximize the level and distribution of health and well-being by focusing on people's needs and preferences (both as individuals and communities) as early as possible along the continuum from health promotion and disease prevention to treatment, rehabilitation and palliative care, and as close as feasible to people's everyday environment.

With its emphasis on promotion and prevention, addressing determinants, and a people-centred approach, PHC has proven to be a highly effective and efficient way to address the main causes of, and risk factors for, poor health, as well as for handling the emerging challenges that may threaten health in the future." WHO Vision for Primary Health Care 2018

OUR FUTURE CARE MODEL – STRATEGIC AIMS FOR PRIMARY CARE  

As we look to deliver Our Hospital as part of a Jersey Care Model, remodelling our Primary Care is imperative  so that we can achieve the goals of the CSP. We intend to;  

1. Innovate and promote resources that help citizens with self-care for themselves, their families and  loved ones to improve health outcomes  
2. Expand and enhance prevention and screening to identify and treat risk factors, pre-cursors and  disease as early as possible (Appendix 4)  
3. Improve and remove potential barriers to access for patients who are financially, clinically and socially  vulnerable  
4. Maintain the existing excellent rapid access to Primary Care services  

5. Re-purpose existing Secondary Care resources into preventative and Primary Care services, thus reducing current over-reliance on our Secondary Care services
6. Provide and support high quality multidisciplinary care, 24 hours a day, 365 days a year – with the right care in the right place at the right time

Our strategic aims require a Primary Care sustainable Island workforce model, educational and training strategy, and joined-up' digital strategy, which interfaces with all other health and care provision. There is also a requirement for enhanced support for carers and inclusion of the future External Partner and Secondary Models to ensure equity and efficiency of care.

IMPROVING ACCESS TO SPECIFIC PRIMARY CARE SERVICES FOR SPECIFIC GROUPS

We will consider all opportunities for expanding access to Primary Care for those who are financially, clinically and socially vulnerable. This may be achieved by a combination of financial support, education, cultural champions and availability of services in alternative locations.

Financially vulnerable

• Support for those who are unable to afford the service user co-payment (in the short or long term) by expansion of the income support system (use of Primary Care Medical Cards etc.)

Clinically vulnerable

• Review of the current system for providing dental services for children in Jersey, to look at other potential models of care which could provide more timely access for all children

• Developing clinical pathways for long term conditions such as Diabetes, COPD, Cardiovascular Disease, Depression, Epilepsy and End-of-Life Care (Appendix D)

Socially vulnerable

• Support for specific age groups, e.g. all under 5s, all children, teenagers with specific conditions or the over 85s

• Vulnerable adults – access to a range of primary care services via a multidisciplinary clinic based at the Shelter and other similar External Partner facilities

Alternatively, a 24/7 hospital based Primary Care service could provide specific Primary Care services for those otherwise unable to access care (Salaried GPs, Urgent Care Centre, Clinical Practitioners) and provide support for all other 24/7 services – Acute Floor, Ambulance, Talking Therapies etc.

PREVENTION AND SCREENING

Identifying disease earlier, and managing health and care better, means healthier, longer lives for the population. For every £1 spent on prevention, £1.90 could be saved that would otherwise have had to be spent on treatment.

Opportunities for expanding prevention and screening include:  

• Pneumococcal Vaccination programme  

• Expansion of smoking cessation programme to practice nurses  

• Dental caries prevention for children  

• Five yearly Health Check for all those aged 40-74 including screening for alcohol and tobacco use,  hypertension, obesity, cholesterol, diabetes, depression with appropriate follow up  

• Make Every Contact Count (MECC) using every interaction to promote the benefits of healthy living  

Prevention services should be provided by a range of disciplines in a range of settings in a clinically and cost- effective way.  

To achieve real and sustained action on prevention, activities need to be co-ordinated and collaborative working with the Strategic Public Health Unit is essential.

DEVELOPING THE MULTIDISCIPLINARY WORKFORCE

Jersey has long been reliant on the General Practitioner as the main provider in Primary Care. Whilst continuing to value our GP workforce we will move away from this outdated model to a multidisciplinary approach, with the patient at its heart.

We will consider expanded roles including:

• Pharmacists – non-medical prescribing, supporting GP practices and Care Homes, funded Medication Use Reviews, preventative services

• Nursing – expand use of Practice Nurses, non-medical prescribing, long-term conditions management and intermediate care, prevention

• Physiotherapy – we will assess the viability of direct access physiotherapy for musculoskeletal conditions, increase community exercise programmes (e.g. frailty), consider non-medical prescribing if appropriate

• Mental Health workers – There is no health without mental health' and primary mental health care needs to be as accessible as any other – we will review primary mental health care, explore use of Primary Care mental health workers in practices, encourage mental health first-aid at work training, and develop online cognitive behavioural therapy (CBT) delivery (GP cluster work ongoing)

• Social prescribing – linked with the Closer to Home initiative – we will build a network of community support resources, with a single point of access to multiple services based in community hubs advising on resources available – e.g. walking groups, community groups, exercise as medicine initiatives (exercise referral scheme). This will also improve support for carers.

We will move Secondary Care services into the community, through the development of Primary Care Practitioners with Special Interests, e.g. Dermatology. We will provide high quality multidisciplinary care, 24 hours a day – with the right care in the right place at the right time. We will address the current funding mechanism to facilitate expansion of these services – including review of the potential to expand the use of the Health Insurance Fund to allow increased funding for a range of providers.

FUTURE FUNDING MODELS FOR PRIMARY CARE

There is agreement across the Island that the current funding model for Primary Care will not allow our strategic intent to be deliverable. Previous reviews (Deloitte, KPMG) have identified inequity and barriers to transformation of care within Jersey and we only have limited government financial levers (JQIF) available to improve outcomes, allow more care to be delivered closer to home and encourage self-care. There are a multitude of international models to assist our deliberations, ranging from;

• NHS Care (majority is free at point of access, e.g. GP services), salaried GPs.

• Social health funds, Household Medical Accounts, Universal Medical Cards.  

• Private / public health insurance schemes (Holland as an example)  

• Blended models (the majority), whereby there is a mixture of user pays', capitation (payment for list  size or special groups), fee for service payments and various Performance Related Framework  payments from central government (JQIF)  

Funding for Primary Care services in Jersey is sourced from a combination of; service user co-payments,  payments from the Health Insurance Fund (HIF), and payments from Health and Community Services (paid for  by general taxation)[1]. Increased provision of Primary Care services is likely to require extra funding, repurposing of current budgets or reducing the spend on Secondary Care into the future;

Reconfiguration of current funding streams

• Moving funds and resources from secondary to primary care with concomitant activity changes

• Combination/redistribution of the HIF and HCS budgets

• Ring fenced budget for prevention and screening

Potential new funding streams

• Expand public contributions to social security or general taxation/indirect taxes/charges

• Prescription charges for some medicines

It should be noted that there is the potential to access funds from the HIF on a one-off basis in order to offset double running costs in primary and secondary care during a period of transition.

CONCLUSIONS

Significant work is still required to achieve sustainable implementation of our strategic objectives. In particular early work is required for the development of a clinical forum and clinical pathway design process, and a combined strategic needs analysis. A pan-island workforce planning exercise is required to develop a comprehensive business plan for the provision of 24-hour multidisciplinary primary care, 365 days a year.

We also need to ensure our Primary Care Strategy aligns and supports the wider Jersey Model of Care to allow the CSP vision to be fully realised.

Political direction and robust financial modelling are essential in order to make informed decisions about the future of funding and access for prevention and Primary Care in Jersey.

PREVENTION & PRIMARY CARE APPENDICES

Prevention & Primary Care Appendix A: The Common Strategic Policy re Primary and Prevention

Prevention & Primary Care Appendix B: Definitions

Prevention & Primary Care Appendix C: Population demographics and multi-morbidity projections Prevention & Primary Care Appendix D: Long-term Conditions

Prevention & Primary Care Appendix E: Strategic Aims – more details

Prevention & Primary Care Appendix F: Enabling the Strategy

Prevention & Primary Care Appendix G: Notes on Intermediate Care

Prevention & Primary Care Appendix H: Current Funding Sources

Prevention & Primary Care Appendix I: The Future of Funding for Prevention and Primary Care Prevention & Primary Care Appendix J: Primary care pharmacists - example of value opportunity

INTERMEDIATE CARE INTERMEDIATE CARE INTRODUCTION

Intermediate care is a multidisciplinary service that helps people to be as independent as possible. It provides support and rehabilitation to people at risk of hospital admission or who have been in hospital. It aims to ensure people transfer from hospital to the community in a timely way and to prevent unnecessary admissions to hospitals and residential care. It is critical in supporting the patient to avoid Secondary Care admissions or long lengths of stay in acute bed, which are costly and not the best course of action for the patient.

CURRENT POSITON

The current position on the island is as follows;

• Intermediate care offer is delivered in partnership with FNHC

• The current specification and offer are not an optimal solution when considering other models and the needs of a re-shaped hospital

• In 2018 the Rapid Response and Reablement Service averaged around 300 referrals per quarter

• The Top five conditions reported (2016) were wound infection, orthopaedic, falls, urinary infections and reduced mobility

• Current service has been hampered by gaps in the workforce

• The most common destination for onward referral was GPs in 2018

• The most common equipment provided was washing and dressing aids

High level data from our service provider demonstrates that majority of our services are delivered to those with the highest need and there is room for expansion to support more people in their own homes. In 2018 the following total care days were provided:

• 4,126 level 3 (General Inpatient Care)

• 801 level 2 (Continuous Home Care)

• 971 level 1 (Routine Home Care)

• 1,482 community mental health

FUTURE STATE

A high functioning intermediate care offer is imperative to delivering a health and social care system that is firmly embedded in the community. To deliver such an improvement will require a detailed specification which includes the following NICE guidance. A specification tailored to Jersey will be developed on this framework, significantly enhancing the level and frequency of service provision in this area  

Key Service Attributes for Jersey  

We will establish a Community Independence focussed Intermediate Care function which incorporates Frailty  and Older Person's Rapid Access.  

The service is proposed to be available 7 days a week with a minimum 8am-8pm function but connected to a  core overnight community function.  

We expect the service to provide;  

• Urgent Rapid Response (Nursing Assessment and Support - Intervention)  

• Urgent Social Care Assessment and Support – Care direction

• Urgent Therapy Assessment and Support (Physio and / or Occupational therapist) – equipment and support

• Rapid deployment of Reablement support or enhanced care at home

• Integrated liaison to the Mental Health Crisis Prevention Service

• Night sitting deployment

• Integrated Medical support to broaden the intermediate care scope

The service would be made up of Nurses, Social Workers, Therapists, Reablement workers, Mental Health staff and connected to but not driven by a medical model which incorporates Primary Care and Care of the Elderly specialist opinion.

The service would have rapid access to Secondary Care diagnostics, step up-down provision and home facing enabler services (handyman and parish-based offer etc)

The service will be connected to a broader community services specification to support 24/7 care needs including end of life care. The service will work with the Closer to Home initiative.

This service will help support the changes in the social and long-term care sector (residential and nursing) from bed based to home faced care provision around a personalisation agenda.

Key Expectations of the Service

• Improved Quality of care delivered in the right setting by the right professionals

• A reduction in admissions to the Acute sector for target groups (Ageing Demographics and Chronic conditions)

• Early facilitated discharge from the Secondary Care setting which improves Length of Stay (LoS) and  drives a Discharge to Assess model  

• A reduction in intensive and high cost packages of care  

• A reduction in placement prevalence (Nursing and Residential)  

• Reduced professional contacts and duplication  

• Reduced Mental Health crisis activity  

• Reduction in adverse safeguarding outcomes  

• Reduction in interdisciplinary and inter-provider related incidents  

• Improved service user experience and outcomes  

INTERMEDIATE CARE APPENDICES:

Intermediate Care Appendix 1: Intermediate care service definition (NICE)

SECONDARY CARE

SECONDARY CARE INTRODUCTION

In order to meet the long-term care needs of the Island the Department of Health and Community (HCS) will need to ensure there is an effective Acute Services Strategy (for hospital services) in place. The department has already undertaken significant work in this area and The Acute Service Strategy' 2015-2024 detailed a high-level direction of travel for the core acute service at Jersey General Hospital.

The case for change for the previous Future Hospital scheme also outlined many of the same issues to address in order to sustain acute hospital services. The population of Jersey is growing relatively slowly but is ageing rapidly. Between 2010 and 2040 there will be a 95% increase in the over 65 population, with a 35% increase by 2020. This growth in the older adult population will create a challenging increase in demand for Health and Community Services. Subsequently, the Acute Service Strategy 2015-2024 predicted that current services could not accommodate this increase in demand and the island will run out of capacity in key service areas (E.G Theatres, In-Patient Ward s) in the next five to ten years.

The previous Future Hospital proposal was for significant expansion of Acute Hospital capacity in order to ensure the needs of the people of Jersey can be met in the future.

The Executive team are in the process of reviewing the Acute Services Strategy and previous Future Hospital Outline Business Case (OBC), and, there are clear considerations for a change in direction in the way we establish future hospital Secondary Care services.

CURRENT STATE AND KEY ISSUES

There are many factors that need to be considered in determining the future hospital Secondary Care requirement, and, it is important to note that healthcare is a continually evolving service, which requires flexibility and innovation. There are many issues to note in relation to the current state and as is' position;

• The current acute hospital/Secondary Care system cannot be sustained in the existing hospital building, and, there is clear recognition that the original Case for Change' for a new hospital remains.

• The current service reflects that of a small District General Hospital' which doesn't necessarily match the demographic pressures the Island faces. The previous OBC for the Future Hospital determined more beds would be required to meet the needs of the ageing demographic, but, modern health and care strategy would determine that institutional bed-based services are not always the best solution for these pressures. We believe the future model of Secondary Care should not mirror the NHS District Hospital specification and should reflect more modern and international concepts for Hospital services.

• The model of care for the Island is currently over reliant on beds' both in and out of hospital.

• The current service has workforce and operational challenges.

• The system is not digitally optimised.

• Mental Health has not been considered to be in scope previously, but we believe it is integral to the future state.

• Optimising truly integrated physical, mental and social care services has not been considered enough in future physical capacity requirements of the new hospital. In determining future hospital needs there must be interrogation across the entirety of the health and care system and its strategic capability.

The clinical and professional leadership teams across HCS believe the model of care delivery in Jersey needs to  change. In essence our system of healthcare has focussed on an over reliance of bed-based care within  

institutional care settings from Hospital to Residential and Nursing care. Given the most significant demographic of health care utilisation is amongst our older population it is therefore important that our system of care reflects this need.

FUTURE STATE: SECONDARY CARE MODEL

The Executive and newly formed senior clinical and professional leadership team have been considering the future care model requirements for the Secondary Care system (Acute General Hospital). Key conclusions include;

• The Front Door of the Hospital will require an Emergency Care Centre that provides all of the existing Urgent and Unscheduled Care access. Appendix B outlines the current and projected Emergency Care Capacity requirements and proposed future pathways in more detail.

On reviewing the existing data and future projected need there is an opportunity to change the Accident & Emergency service into an Emergency Care department. HCS believes the future model of care must ensure the Emergency Care department maintains the ability to manage urgent, very urgent and  resuscitation  patient  activity  with  a  specialist  medically  led  model  of  Emergency  Care.  The Emergency Care department will also need close connectivity to the proposed Acute Floor Model concept. An Acute Paediatric Assessment Unit should be provided in a co-located Emergency Care setting, this should include shared care facilities for CAMHS (Child & Adolescent Mental Health Services) patient pathways.

Non-urgent and standard activity which is a significant part of the current volume of patients could be managed within an urgent care centre that is closely connected to the Emergency Care department. The Urgent Care Centre (UCC) will need careful consideration in relation to policy as a high volume of the activity could be considered to be minor illness that can be managed by Primary Care. Further analysis will be needed in relation to charging consideration and the role of Primary Care in managing this volume of patient activity.

• Ambulatory Assessment needs to be more prominent and this particularly includes Older Person's Rapid Access to multi professional services outside the Hospital.  

• Inpatient capacity (the number of beds) need to be set to trajectories of need based on effective integrated care pathways. Our initial evaluation indicates that there should be no increase in bed base beyond the current position. We are anticipating a range of 150-210 beds, but further modelling is required. This is a smaller bed base than the previous scheme at circa 280 beds (Appendix C). The clear rationale for this change is that the demographic growth outlined in the previous OBC should have targeted Out of Hospital services as an alternative to bed-based care. The assumptions in Appendix B also identified the existing and future hospital bed base can be further optimised by an  improvement in Length of Stay and more focus on Ambulatory assessment and admission avoidance  schemes.  

We believe that specialist functions and inpatient capacity will still be required as identified within the  previous OBC for Women and Children's services, Neonates and Critical Care. Further analysis is  required to determine the specific volumes of activity anticipated.  

Infection Prevention and Control compliance with isolation capacity will need to be maintained and  we believe the previous concept of adaptable wards to ensure sufficient cubicle capacity that includes  flexibility to open bays is the best option for the new Secondary Care facility. Specialist functions such  as theatres, cardiology, renal, pain services etc. will be set to effective clinical pathways based on  

island need and so we would anticipate increased day surgery and endoscopy capacity based on current disease prevalence analysis. Appendix E outlines the opportunity to improve day case utilisation and theatre efficiency in the Secondary Care system.

• An Integrated Care Hub model will ensure the continuity of care required within the health and care system. This will ensure we have efficient planned care services that connect Primary and Secondary Care and so replacing traditional outpatient services. Appendix D considers the existing outpatient activity for the Secondary care system.

Our new approach would see a transformation of the way outpatient services would run with an aim to connect care for adults and children between Primary and Secondary Care. Early results from similar schemes indicate reductions of up to 40% in outpatient activity with alternative processes set up to ensure immediate specialist advice and guidance for GP's is available. This approach reduces unnecessary waits for patients and ensures the secondary care system is able to focus on the more specialist and acute care needs for the Hospital.

• Clinical Support and Cancer Services: Clinical support services will be needed including increased clinical Investigations capacity, MRI and CT scanning capability as well as mobile equipment functions. Pathology and Wider Radiology is broadly expected to be in line with previous scheme expectations but with increased connectivity to Primary Care and more near testing' capability. Cancer services need to be prominent and the department needs to develop a cancer strategy for the Island.

• We anticipate that the new Secondary Care hospital system will have Co-located mental health services for inpatient beds along with enhanced community services focussed on crisis prevention and intervention. The Hospital care environment needs to be dementia and cognitive impaired friendly.

• Connectivity to tertiary and specialist services via a Jersey Emergency Transfer Service is required as well as planned tertiary care services. We anticipate more patient activity can be repatriated to Jersey in a modern Hospital facility and there is significant opportunity of working more closely with Guernsey. Critical Care and Outreach will need to be in place.

• The Hospital must be Digitally Optimised.

• The health and care system needs to establish a more comprehensive intermediate and community care model so that hospital capacity is protected for acutely unwell patients and to meet the demographic needs of the Island.

KEY DIFFERENCES TO PREVIOUS FUTURE HOSPITAL PLAN  

We anticipate the future Secondary Care (Acute General Hospital) system should provide many of the existing  and previously planned functions. There are however some different characteristics envisaged to the current  Hospital, and, proposed changes when compared to the previous OBC for the Future Hospital. In essence, we  believe the future hospital should be smaller in scale than originally proposed.  

Key Differences;  

• The bed base of the Hospital would remain a similar level to current state and be circa 80 beds less  than proposed in the previous OBC.  

• Services such as Physiotherapy, Podiatry, Long Term Condition Management and those outlined in  Appendix G can be partially or fully provided in an alternative care setting outside the Hospital  

including home focussed community care. Any re-provision outside the future hospital would need to ensure the de minimus of the hospital isn't compromised so that the facility is able to run in the most efficient way.

• The Outpatient service is proposed to operate in a different way by adopting virtual Hubs for specialist advice and guidance and continuity in care that connects the entirety of the health and care system. The new approach for planned care management and in particular chronic disease management would see the previous Westaway Court' concept removed from future plans. The activity planned within the Westaway court concept is believed to be adaptable and more appropriate for Primary Care services with close connectivity to specialist Secondary Care via a virtual Hub' concept, with Secondary Care clinicians providing advice and guidance to Primary Care.

• Capacity in the future building should be modular in nature so that clinical environments can be adapted to reflect demographic pressure areas such as gastroenterology, renal or cancer services for example where increased capacity may be needed. The environment should also be flexible enough to adapt to future care innovation for increased day surgery and non-invasive procedures, which can result in requiring fewer inpatient beds.

• The new facility should be co-located with a small inpatient mental health unit (Campus model) so that services can be closer integrated. This will ensure clinical and non-clinical support services are concentrated in one campus rather than spread across the Island as they are currently.

• The new facility needs greater ambition for digital optimisation than the previous scheme, which is again anticipated to impact on the physical scale and requirements of the Hospital.

• The new facility needs to operate with confidence that out of hospital primary, community, social and intermediate care services are managing increased activity, therefore protecting the Acute Hospital capacity for true hospital-based care need.

SECONDARY CARE CONCLUSION

The Future Care model for secondary services is one part of a wider health and community system. It should be noted that most health and care needs to happen outside the Secondary Care setting. The Government Plan in line with all health and care strategies across modern jurisdictions focusses on greater prominence for prevention, early help services so that over reliance on secondary healthcare systems is mitigated.

The revised Acute Services Strategy would envisage;

• More responsive service for islanders with quick access to hospital services both planned and unplanned

• An improved quality of services for islanders with enhanced environments of care and better- connected health and care services.

• More care outside the hospital

• A more comprehensive community and out of hospital system  

• A revised social care system which reflects the needs of the island  

• An attractive workplace for key professional groups in an innovative and creative environment  

• A long-term sustainable health and care system for Jersey  

• The potential to repatriate off-island activity and provide care pathways closer to home  

• A more productive and efficient health and care system to ensure the Jersey pound' is well spent  

With a revised ambition we believe the future Secondary Care system in Jersey can be a beacon of innovation,  working as a centre of excellence for care which will sustain the long-term provision of Secondary Care on the  Island. The services can attract a workforce of the highest calibre and is able to match the economic enterprise  and opportunity of the Island's wider services such as financial services.  

SECONDARY CARE APPENDICES Secondary Care Appendix A: Emergency Care

Secondary Care Appendix B: Bed Base

Secondary Care Appendix C: Planned Care

Secondary Care Appendix D: Day Surgery-Theatre Utilisation Secondary Care Appendix E: Step Down & Intermediate Care Secondary Care Appendix F: Hospital Services Analysis

MENTAL HEALTH

MENTAL HEALTH INTRODUCTION

The following statement gives a high-level overview of the strategic improvement agenda and vision for mental health services. It builds on the Jersey Mental Health Strategy 2016-20 as well as more recent assessments such as the Health and Social Care Scrutiny review of mental health care on the Island. It reflects and summarises the response to the scrutiny findings and recommendations and other relevant external reviews of the Islands mental health services. It outlines an ambition to deliver a good mental health service in Jersey starting with the mission and vision we have for the service and the underpinning values that will guide our work.

Our mission is to improve the mental health and wellbeing of Islanders (Objective 2 Common Strategic Policy) through services which are recovery focused, person centred, and integrated incorporating legal safeguards and practices that facilitate community partnership and social inclusion.

VISION

Our vision is for an island that is humane, socially just, caring and responsive to those who are mentally ill and those who experience issues impacting upon their mental health and wellbeing; a place where individual rights are upheld, and all aspects of Island life enable the opportunity for those experiencing mental illness and/or distress to recover and restore their lives free from discrimination, stigma and prejudice.

KEY ISSUES

The challenges facing our Mental Health Services are well known and some elements are consistent with most health and care jurisdictions. Key issues;

• We face a recruitment challenge for key skilled roles such as Registered Mental Health Nurses, Medical Staff and Allied Health Professionals.

• Our mental Health Estate doesn't provide a therapeutic environment of care

• We are seeing increased activity in Mental Health services

• There is a lack of care co-ordination and over reliance on the voluntary sector

• The wider system of Government such as Housing and Economic prosperity need to be linked to our strategic plans for mental health

PLANS

We believe mental wellbeing is essential to personal aspiration and development. All stakeholders have a role  in supporting and enabling people who experience mental ill health to live meaningful and productive lives.  

Over the next 5 years we will:  

• Review and manage our capacity and demand for care by redesigning our mental health care system  

• Develop community-based alternatives to hospital-based care and offer timely integrated crisis care  and support over a 24-hour period.  

• Significantly improve the safety and effectiveness of services using data and evidence to drive quality  improvement and optimal performance  

• Invest in Primary Care led mental health and focus on preventing mental ill health as well as  intervening early to give people the best chance of recovery  

• Work with local communities and a range of partners to promote social justice and expand capacity for recovery-oriented care and support (e.g. housing, employment, social support)

• Invest in digital solutions which can transform the care experience and bring therapeutic benefits to all ages and complexities

• Stabilise our workforce by investing in people with relevant experience, knowledge, skills and competence who are committed to Jersey and can work together to make the best use of the talent and resources available on the Island

• Enhance the fabric and design of our facilities

• Listen to and value the experience of those with lived experience and work with them to improve our mental health system through co production and service evaluation

• Embed an organisational culture that embraces all of the above values in the systems, processes and institutions within our island community

TRANSFORMING OUR CARE OFFER

It is our belief that transforming the mental health care system in Jersey will only be achieved if the need for better mental health care on the Island is fully recognised and demonstrated by our collective commitment to the mental health goals identified within the Common Strategic policy. As a Government we are serious about and fully understand our responsibilities to deliver this requirement and involving all Government departments.

Person centred care, shaped (importantly) by the experience of those who live with mental illness is at the heart of this transformative process and is the means by which people are helped and supported as an equal partner in their own care to recover and regain their usual life. We know better outcomes are achieved when services are community based, recovery oriented, integrated and evidence based and when the system of care embraces the principle of co-production[1] and partnership.

We know individual and community resilience is possible when all community assets are engaged in working together to promote positive mental health and wellbeing and social justice and that mental ill health can be prevented by providing early intervention and high-quality treatment and support services. Our ambition is to strengthen the quality of delivery by supporting and facilitating Primary and Secondary Care services, External Partners and all government departments to work together, collaboratively and productively to achieve this outcome.

By working with local communities, colleagues in other Government departments e.g. Primary Care, housing, education, criminal justice and home affairs, and employers and local businesses we believe people of all ages with mental health needs will benefit from a model of care that provides the right care at the right time in the right way by the right people. We call upon all stakeholders to embrace and adopt person centred recovery' as the model of care in Jersey. Our purpose is to bring hope and offer choice to individual islanders who can define for themselves what it means to live a fulfilling and productive life. We know this approach positively  changes lives.  

STRATEGIC AND IMPROVEMENT OBJECTIVES  

The Mental Health Improvement Board has approved 5 high level objectives to secure improvements in  mental health services:  

1. STABLEANDHIGHPERFORMINGWORKFORCE

"Our workforce is skilled, motivated, resilient, and committed to delivering excellent services to people with mental health needs. They are confident and feel supported make decisions, assess and hold risk and to develop and create innovative solutions".

2. IMPROVINGTHEEXPERIENCEFORPEOPLEWITHMENTALHEALTHNEEDS

"Our recovery focused service offer is person centred and rights based providing the right intervention at the right time in the right way through the delivery of an integrated service that starts with prevention through to specialist support".

3. PREVENTIONANDEARLYINTERVENTION

"We intervene early to prevent deterioration in mental health and wellbeing to enable individuals to flourish and remain as active citizens so that they can continue to lead a usual life.

4. APPROPRIATEENVIRONMENTANDFACILITIES

"People are supported in a person centred and least restrictive way. Wherever possible this will be at home or in the community but when they cannot remain at home, they will have access to services and facilities that are of high quality in facilities that address their immediate need and support their recovery; accessing a wide range of therapeutic services will ensure they have the best opportunity to recover and flourish".

5. CUSTOMERFOCUSEDDELIVERY

"Our services are outcome driven and we are clear about the impact we are having on people's lives. The mental health outcomes achieved demonstrate we are providing a high performing service".

The following strategic framework proposes a basic logic that we will apply in pursuit of these objectives and associated outcomes. It is a simple logic based on shifting our current pattern of service to that which is more aligned to prevention, early detection and early intervention.

We plan to shape the economy of our resources and transition these in ways that remove inefficiency and  ineffectiveness to deliver real improvement in the quality and value of the service we offer. We will be  enterprising and constantly seeking new ways of working to improve our productivity and deliver good care.  Our ambition is to deliver a care experience that is timely, personable and equitable, shaped, informed and  

influenced by advances in technology and innovation, relevant evidence and the experience of those who use services. The dimensions of our work will include;

1. Redesigning the model of care and support
2. Improvement activity
3. Commissioning and Strategy and policy development

INPATIENT SERVICES

The latest bed analysis for inpatient Mental Health services indicates the bed ratio is broadly in line with the UK. The recent appointment of new medical staffing has also had a positive impact on reducing Length of Stay and Occupancy across all 3 units. Going forward the impact of the Crisis Prevention and Intervention service will also have an impact on the number of beds required for mental health services. A Mental Health steering group is reviewing this position and a co-located inpatient service within the main hospital is the preferred option at this stage, but it should be noted the full impact of the 24/7 Crisis Prevention and Intervention service will have significant impact for inpatient configuration.

MENTAL HEALTH CONCLUSION

The statement "Without mental health there can be no true physical health" [1] was made by the first Director General of the WHO over half a century ago. In 2011 the UK Government adopted "no health without mental health" as the starting position to develop their strategic ambition to mainstream mental health care in England. A change never seen before was evident in this strategy - the focus on outcomes and the importance of public health and social justice as the cornerstones of better mental health. In Jersey, we have set out our own immediate outcomes and pursuing these until we start the refresh our strategic ambition from 2020 and beyond.

By proactively tackling the wider underlying causes of mental ill health, increasing access to preventative care and support, treating people quickly and effectively, promoting their rights and addressing social injustice we will be successful in helping people regain their hope and choice for the future not only for themselves and their families but for our One Island community.

The Our Hospital programme will need to consider the long-term requirements of Mental Health services as part of the a ONE HCS strategy that encompasses the entirety of the Health and Community estate across the Island.

In essence, HCS has concluded that we will require;

• A new Hospital facility that embraces Physical and Mental Health services with consideration for shared care needs and dementia friendly environments for older adults.

• A co-located physical and mental health facility is favoured at this stage – as a campus style facility.

• Outpatient support will need to be part of the integrated hub model of care as outlined in the secondary care model.

• Increased support of Mental Health in Primary Care and Community services will be required.

• Tertiary Pathways for specialist care will be required off island. The department will consider provider options in partnership with Guernsey.

• Child and Adolescent Mental Health support will remain a community focussed service delivered in partnership between CYPES and HCS. Inpatient facilities will be required for shared care purposes within the new Hospital and the Island should explore the potential for on island specialist provision (an off-site facility), again in partnership with Guernsey.

• Full benefits realisation of all Government Plan schemes is required;

• Full roll out of the Crisis Prevention and Intervention service
• Full implementation of the Complex Trauma Pathway
• The Listening Lounge and Place of Safety schemes
• A clear strategy for Dementia and Suicide prevention
• A Partnership of Purpose between the Government of Jersey and External Partners.

Our analysis (Mental Health Appendix A and B) demonstrates there is increased opportunity to have a small inpatient bed base for mental health care along with an enhanced community offer to address the increasing needs. The system of care will need to consider longer term specialist activity which is managed off island at present and consider if there is a case for change for more repatriation of this activity back to Jersey rather than using UK based providers. Further feasibility reviews and assessments are needed in this area.

The Child and Adolescent Mental Health service also requires further review with collaboration from the departments Health and Community Services (HCS) and Children, Young People, Education & Skills (CYPES) as it is clear that on and off island care pathways need to be re-designed.

As part of the Government Plan HCS has submitted a number of business cases outlining strategic intent for adult, child and adolescent mental health services which can be found in Appendix C.

MENTAL HEALTH APPENDICES

Mental Health Appendix A: Inpatient Activity

Mental Health Appendix B: Community Based Activity

Mental Health Appendix C: Government Plan Business Cases for Mental Health

CHILDRENS' HEALTH

Children and Young People's Plan

The Children and Young People's Plan 2019 to 2023 is a fundamental new plan for Jersey's children, young people and families, which aims to make sure Jersey is the best place to grow up and also improves everyday lives. The Government of Jersey has developed the plan to achieve better outcomes for children and young people so that they have the brightest futures possible.

For the next four years, everyone who works with children and young people across the Government will use the Children and Young People's Plan to help them decide what they need to do to ensure that all children and young people:

• grow up safely

• live healthy lives

• learn and achieve

• are valued and involved

Developing and implementing a new Children's Plan for Jersey was recommended by The Independent Jersey Care Inquiry panel in its findings on 3 July 2017.

Health and Community Services - All children in Jersey Live Healthy Lives Ambition

We want children to be heard, valued and involved in the decisions that affect their everyday lives, regardless of where they live or the school they go to.

Why?

Good health is an essential foundation for children's quality of life. Often healthy behaviours (e.g. a balanced diet, regular exercise avoidance of tobacco and alcohol) established in childhood can last into adulthood and reduce the chances of developing a chronic condition later in life. There can be no health without mental health, yet demand for child mental health services are continuing to increase. Timely access to health services is important in securing a healthy start to life. In addition, wider factors such as good quality housing, active transport, and access to parks and countryside are recognised as having a key role to play in supporting healthy childhoods.

Key Policy Areas

• Public Health Strategies

• Mental Health Strategy

• Disability Strategy

• Sustainable Transport Policy

• St Helier Masterplan

• Primary Care Strategy

• Open Space Strategy

• Culture Strategy

Connecting Care for Children

We aim to deliver an integrated care model which will improve continuity of care for our children in Jersey. This will address the high rates of paediatric A&E and paediatric outpatient attendances at the General Hospital and enable our GP's and community services partners to provide many of the services currently offered within the General Hospital. In order to achieve this we will be working with local GPs, community partner leads and our social care partners in children's services.

Our model will have key components:

• Public and patient engagement - enabling primary, secondary and community care professionals to work cohesively with islanders. We aim to ensure the public are clear of services offered and how to access them.

• Specialist advice and guidance – we aim to transfer specialist knowledge from the hospital to the community. Hospital paediatricians will work closely with GPs so that children receive the best possible advice and care within home and community settings.

• Open access - making the expertise of paediatricians in hospitals much more widely available. We will establish direct access to specialist advice and guidance which, primary and community healthcare professionals can access when they need specialist support.

At the core of the model we support healthcare education and training. We ensure primary and community healthcare professionals have the information they need to provide care at home. We will also increase education events for patients and families so that they can learn how to stay healthy and what health care services are available to them.

We will also work closely with our partners in Children, Young People Education and Skills (CYPES) to support the wider Government agenda on delivering preventative services. This will build on our Early Help' approach and will ensure that our functions and services are closely aligned to the wider children's services across the Island. A key area of focus for HCS and CYPES will be to improve care and support for Child and Adolescent Mental Health services in Jersey and both departments have a role to play in driving better early intervention and improved access for services.

ADULTS SOCIAL CARE

Health spending has risen steadily over the past three decades and has accelerated since the turn of the century to average 8.8[2]% of Gross Domestic Product (GDP) for countries that were members of the Organisation for Economic Co-production and Development (OECD). It is anticipated that if no specific policies are employed to move away from current trends the health sector spending is projected to rise to nearly 14% of GDP by 2060[3].

Although people are living longer than in the past, the functionality of the human body inevitably declines over time, thereby increasing demand for health and social care products and services.

Jersey has an ageing population like many jurisdictions and to support people we need to be innovative and change our current model of delivery which is not sustainable. If we consider the below diagram we can see that our use of residential beds has been significantly higher than anywhere in the UK. Unless we change direction, these pressures will impact the entire Jersey economy.[4]

We will need to work in partnership with Customer and Local Services (CLS) to reduce the pressure on the Long Term Care (LTC) fund to develop the introduction of personal budgets which will increase the range of services available to support people in the community as well as increasing the number of people who can be paid carers. £46.97m paid to support 1,320 people in long term care. 85 people were supported each month (on average) to continue living at home with a domiciliary care package, where the individual needs are particularly complex, and costs exceed the Long Term Care Benefit. HCS also spend around £5.8m annually on packages of care and respite that do not meet the criteria for the Long Term Care fund.

SOCIAL CARE PERSONALISATION

A different adult social care model is required to achieve sustainable services for adults who need care, and  sufficient choice for adults with varying needs which may change over time. Personalisation means recognising  people as individuals who have strengths and preferences and putting them at the centre of their own care  and support.  

The traditional service-led approach has often meant that people have not been able to shape the kind of support they need or received the right help. Personalised approaches like self-directed support and personal budgets involve enabling people to identify their own needs and make choices about how and when they are supported to live their lives. People need access to information, advocacy and advice so they can make informed decisions.

Personalisation is also about making sure there is an integrated, community-based approach for everyone. This involves building community capacity and local strategic commissioning so that people have a good choice of support, including that provided by user-led organisations. It means ensuring people can access universal services such as transport, leisure, education, housing, health and employment opportunities. All systems, processes, staff and services need to put people at the centre.

• Personalisation is not just about personal budgets, but about achieving choice and control in many ways and in different settings, including basic needs such as being able to access public transport if you are disabled.

• Personalisation is about the dignity and well-being of the individual.

• Delivering personalised services will mean different things to different people – it's about self- determination and self-directed care.

• The relationship between social workers/PAs and service users should be based on respect and a recognition of equality.

Personalisation is a social care approach that enables every person who receives support, whether provided by statutory services or funded by themselves, to have choice and control over the shape of that support in all care settings.

While it is often associated with direct payments and personal budgets, under which service users can choose the services that they receive, personalisation also entails that services are tailored to the needs of every individual, rather than delivered in a one-size-fits-all fashion.

It also encompasses the provision of improved information and advice on care and support for families, investment in preventive services to reduce or delay people's need for care and the promotion of independence and self-reliance among individuals and communities. As such, personalisation has significant implications for everyone involved in the social care sector.

Personalisation and service users and carers

The key test of personalisation's success is the extent to which it improves the lives of service users and their carers. Users should assess their own needs, with or without support, play a full part in drawing up a wide- ranging support plan, rather than a narrower care plan, and directly purchase or choose the services they want. Personalisation in other societies is having a significant impact on the roles of social care professionals. The core functions of care management – assessing service users, drawing up a care plan and purchasing services to meet needs – are all transformed through personalised care. This will call upon other  professionals of course in determining more complex needs and in assessing and supporting those needs.  

Instead of purchasing services in bulk from available providers and fitting eligible service users into those that  best meet their needs, commissioners must shape the social care market to promote the availability of a  diverse range of high-quality services from which service users can choose.  

EXTERNAL PARTNERS

EXTERNAL PARTNERS INTRODUCTION

The development of a new hospital for Jersey is well documented and as the project considers a new approach it enables discussions to focus on the size and function of a new facility and crucially what community provision will be needed to support a sustainable health and social care system for Jersey.

Like the rest of the developed world Jersey faces similar challenges such as an ageing population, increased pressure from long term conditions at a time where resources, while still superior to other countries, are rightly under scrutiny. The challenge we have is to spend the Jersey health pound wisely and maximise our current partnerships to deliver the best outcomes for the community.

While central to this is the development of a new hospital, this alone will not provide a sustainable system of healthcare. The new hospital needs to be part of the health and social care system, but it needs to be fully supported by high quality community provision delivered in partnership where people can easily access care and support. Key to delivering a sustainable and quality care system is strong partnerships with the voluntary sector, social care providers, private providers and social enterprises based on achieving shared outcomes.

CURRENT POSITION

We are fortunate to have a strong voluntary sector, that is intrinsically motivated and a social care market that is looking to expand. While this is a strength we lack a clinically led commissioning framework that builds on the partnership approach, built around outcomes. In terms of the local landscape, The Charity Commissioner has received 450 applications for charity registration and the Association of Jersey Charities has around 330 members.

A KPMG report in 2016: The Jersey Charity Survey [5]highlighted the following;

• £80m is raised annually within the sector

• The largest 4% of organisations raised £48m accounting for 62% of all income in the sector

• 1 in 8 adults on the island are volunteering

• Advancement of health was the joint top aim of organisations surveyed and was top of generating income based on organisations aims

• 2/3 organisations operate without any paid staff

• Those 34% with paid full-time staff have the biggest incomes

• 70% of all organisations agree that they rely on regular volunteers but 35% struggle with retention

There is a great opportunity in Jersey to create a different system wide approach that builds on the strengths of this sector through a transparent partnership approach to drive improvement in health and social care across the whole population. The case for change is clear and the need to direct people's attention to what's  important without introducing complexity into the system will require a different relationship. However, there  are a number of areas that can be developed to improve how we support people across the community, such  as;  

• Develop and implement Adults Social Care Strategy

• Improved intermediate care across the system

• Support carers through the Carers Partnership Forum

• Increased care at home

• Market development based on current and future needs

• Introduction of personal budgets

• Increased use of technology to support the delivery of services

• Delivering services where people live using the Parish system

• Workforce development/availability of carers

OPPORTUNITIES

Our partner organisations are ideally placed to support a new and innovative system of health and social care. From supporting homeless people who are 60 times more likely to visit the Emergency Department in a year compared to the general population[6] to access the support they need through to reducing the unnecessary length of stay for some patients in hospital by providing care and support in people's homes through an agile intermediate care offer.

There are a number of opportunities for a partnership approach, to build on the services currently delivered across the island by a range of organisations to improve outcomes for people, make the best use of the resources available and make the Jersey system of health and social care sustainable for generations to come. The implementation of an Adults Social Care Strategy will need to include suitable housing provision for extra care housing and sheltered accommodation to support people's independence in the community for longer.

CARE CLOSER TO HOME

The Health Modernisation Team (HMT) as well as Customer and Local Services (CLS) have started to map a local offer of services that could initially include dementia, mental health, loneliness, social prescribing, and developing a Good Gym model.

This approach includes negotiating the flexible use of local community buildings including schools, Parish and community halls for the provision of activities. It is envisaged that this local offer will be extended to all Parishes based on demographic need and delivering a seasonal offer.

It is proposed that the appropriate redirection of existing resources to a more local, community setting will both have a positive impact on service delivery and will reduce inappropriate referrals to emergency and acute services through a preventative approach. The vision is for services to be delivered closer to or in people's homes.

Closer to home builds on existing strengths and supports self-care and prevention, key components of the  Jersey Care Model.  

The approach also seeks to work with all age groups, not just older, vulnerable residents. Fundamentally the  approach is not only about delivering more accessible services but is also about providing more preventative  services which will ensure long term efficiencies for the Government through keeping people in their home for  longer and avoiding costly care provision reducing both GP and hospital visits and stays.  

This model is an asset-based approach rather than a traditional needs-based approach, whereby services are provided to individuals based on their whole needs of individual support rather than their symptomatic problems. An asset-based approach builds on the strengths of communities and existing services. This approach should lead to increased independence and self-care for individuals in the community and create a menu of services and support that can be universal or part of bespoke packages of care.

To consider an asset-based methodology in providing a range of services in Jersey across all ages, members of the HMT have met with representatives of the Community and Voluntary Sector, Jersey Sport, Children, Young People, Education and Skills (CYPES), mental health services and with the Comité des Connetablés.

A pilot hub has been developed in the west of the island at the Communicare community facility which is situated in a central location within the Parish of St Brelade. Communicare provides a wide range of community activities which successfully attracts a large number of residents accessing the existing offer. The activities include a mother and toddler group, after school club, nursery, youth club, and luncheon club as well as a wide range of other community uses. Both its central location and use by all age groups in large numbers make it an ideal facility to build on. Colleagues from HCS, CLS and CYPES have worked together with staff at Communicare to determine additional services that are offered from the centre.

A steering group has been formed and now includes the local Connetablé of St Brelade, who was selected by the Comité des Connetablés, to oversee the delivery of a rota-based system of services from various providers that is delivered at the Communicare centre and, therefore, closer to peoples' home.

The rota of additional services could in the future include health services such as mental health, chiropody, diabetes clinics and smoking cessation groups, as well as a range of Children's Services such as parenting and family support sessions. Other services such as Social Security drop-ins, Police advice surgeries, and voluntary sector services including Jersey Citizen's Advice Bureau, Mind Jersey are currently delivered there. To maximise the use of a facility that is already incredibly well used a rota system has been developed that publicises the range of services on offer and when they will be available. The "Closer to Home" pilot commenced at the beginning of March with a soft launch and was formally launched in July 2019.

The initial rota has services delivered by the following organisations: Age Concern Jersey, Brook, Jersey Sport, Citizens Advice Jersey, Mind Jersey, Adult Community Services, Library Service, Call and Check, Youth Service, FNHC and Community Police Officers. It is anticipated that this offer will grow and that the steering group will flex and change.

Work has started to look at existing facilities in the east, the condition and capacity of each facility, the services being provided from them and the potential to expand the use of each facility. This should help to develop an appropriate community hub offer in the east of the island. It is anticipated that the "Closer to Home" service will reach across all Parishes working with Connetablés and Parishioners to identify and meet needs.

Initial Feedback

Jersey Library - Children's session:  

"Just one more..." multiple pleas to Mum to be allowed to stay for just one more story (they stayed for about  an hour!)  

"I didn't know you did e-magazines, that's really useful, I'll have a look"  

"Fantastic idea having you here"  

Jersey Library - Adult Session:  

"Thank you so much for the books you lent my husband – just what he needed"  

"We used to go to the library in town all the time but now I don't drive I find it too difficult to carry the books"  

Citizens Advice Jersey

"This is fantastic! I can now get this sorted without having to go to town, thanks for the advice"

Jersey Sport, David Kennedy (General Manager)

"The exercise sessions we have delivered at Communicare have been some of the best that we have been able to deliver. This is due to the help of the staff at Communicare, the opportunity to have a coffee after the session, but most importantly it has been a welcoming environment unlike the gym-based sessions. All participants who took part had never been to Communicare before but really enjoyed it and have said they will be bringing a friend next week. There is a much better community feel about the sessions and we believe this will grow considerably in a short space of time."

Social Work, Kate Profitt (Social Worker)

"I have received a referral from Call & Check for a gentleman who requires social care assessment. This was taken at Communicare, which was key as the referral may not have been spotted this early in the persons set of circumstances if services were not available close to this person's home. This referral will lead to early intervention and prevention work."

"As a result of a social worker being present at Communicare at the same time as Call & Check, networking opportunities have led to an invite for Call & Check to attend the social work team meeting to provide a presentation for Adult Social Care Team."

COMISSIONING FRAMEWORK

As we further develop an integrated health and social care system in Jersey it is vital that our partnerships with providers are open and transparent and our purposes are aligned. There are a number of models that can be considered. It is proposed that a new framework is considered that provides assurance around the quality of services, that the funding model doesn't distract and drive the wrong behaviour, more so it supports the system to deliver the type of care we would all want for our own relatives.

Our relationship with contracted services should be built around a common purpose working in partnership, using payment to support the delivery of care, sharing resources, collaborative working and delivering in the community with clear outcomes. Working to a common purpose across the whole system with all sectors aligned to the new system of care will create an approach to support the most vulnerable in our communities and promote the use of resources in a different way. This will require not only a different approach to commissioning but ongoing work with providers and funders who are not commissioned through Government of Jersey (GoJ) to move to a place where budgets are aggregated as a pool of resource for services to deliver against a common purpose.

Delivering services to an agreed common purpose will require the development and commitment of organisations to work to an overarching Partnership of Purpose this would be the core to all areas of service  delivery and would provide the focus and structure for a framework. This in turn would be supported by an  outcome-based commissioning approach in addition to developing personalisation on the island. This would  see services commissioned for health and social care outcomes not simply measuring throughput of a service.  

Using a co-production model for service development involving both customers and providers, data and trends  would be analysed in order to support market development. A centralised commissioning function with clarity  for accountability in the model and strong governance arrangements to assure delivery against the Partnership  of Purpose could be introduced alongside longer term contracts. Jersey has a diverse health and social care  economy and one format of commissioning will not deliver the results required to improve islander's health,  mental health and wellbeing.  

A hybrid and blended approach will be adopted to ensure proportionality and a focus on outcomes. Our approach will underpin the delivery of the Jersey Care Model by focusing on current and future needs based on evidence while developing partnerships.

Our model will stimulate market development and reward positive outcomes for patients/clients through sharing rewards. The overarching theme of our approach will be place-based systems of care in which HCS work together with partners to improve health and care for the population. This means organisations collaborating to manage the common resources available to them.

The approach taken to developing systems of care will be determined by HCS and partners, based on a set of design principles. These principles include developing an appropriate governance structure, putting system leadership in place and developing a sustainable financial model.

HCS will work to remove the barriers that get in the way of working in place-based systems of care and will work in a co-ordinated way to support the development of these systems. This includes creating stronger incentives for systems of care to evolve to tackle current and future challenges.

Commissioning in future needs to be both strategic and integrated, based on long-term contracts tied to the delivery of defined outcomes. This will enable organisations to plan and develop while underpinning strong partnership working.

Individuals and organisations cannot solve the problems facing today's society on their own. Instead, we must design new ways in which individuals can work together in teams and across systems to make the best use of collective skills and knowledge.

EXTERNAL PARTNERS CONCLUSION

To deliver a new and sustainable system of health and social care requires a new way of working through developing services in the community.  

The Jersey system of health and social care will be delivered by a wide range of partners across the island  delivered where people live. The reach of the system will extend beyond GoJ services into Parishes, supporting  self-care, prevention and early intervention. Partners will deliver services that were traditionally delivered in  secondary health and social care settings in the community using hubs at strategic locations on the island.  

The system will see parity across mental health, physical health and social care and will ensure that we deliver  the Common Strategic Policy priorities of We will put Children first and we will improve Islanders well-being,  mental and physical health.  

To conclude we can't continue to deliver health and social care as we currently do, and we need to develop a modern system that improves outcomes for patients that is sustainable for future generations. GoJ cannot achieve this in isolation and we need a cross sector approach to developing and owning a new system of health and social care for Jersey that is firmly embedded in the community.

EXTERNAL PARTNERS APPENDICES External Partners Appendix A: Introduction

External Partners Appendix B: Partnership framework

External Partners Appendix C: Commissioning Framework Outline

APPENDICES

PRIMARY CARE APPENDICES

>>> Click here to return to Primary Care section

PREVENTION & PRIMARY CARE APPENDIX A: THE COMMON STRATEGIC POLICY RE PRIMARY AND PREVENTION

The Common Strategic Policy published in 2018 was a statement from the Council of Ministers regarding the shared ambitions to "make the positive difference for Jersey that the electorate has demanded".

Five strategic priorities were identified

• We will put children first

• We will improve Islanders' wellbeing and mental and physical health

• We will create a sustainable, vibrant economy and skilled local workforce for the future

• We will reduce income inequality and improve the standard of living

• We will protect and value our environment

While all of these will have an impact on health, the three highlighted directly inform the strategy for prevention and primary care.

PREVENTION & PRIMARY CARE APPENDIX B: DEFINITIONS >>> Click here to return to Primary Care section

Prevention: There are three types of prevention activities that can benefit populations, termed primary, secondary and tertiary prevention:

Source: Adapted from Donaldson LJ, Donaldson RJ (2003). Essential public health, second edition. Abingdon: Radcliffe Publishing.  

In Jersey, primary, secondary and tertiary prevention is facilitated by a range of public and private providers in  a variety of settings.  

Primary Care: Primary care in Jersey consists of general practice services, community pharmacy, dentistry and  optometry. Primary care plays a crucial role in delivering core health care services whilst having responsibility  for referrals to help patients gain access to a large range of other healthcare providers.  

PREVENTION & PRIMARY CARE APPENDIX C: POPULATION DEMOGRAPHICS AND MULTI- MORBIDITY PROJECTIONS

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In the next decade Jersey will face a growing and ageing population, a rising tide of chronic illness, higher expectations of care from the next generation, and the availability of new treatments and technologies.

The resident population of Jersey at year-end 2018  is estimated as 106,800.  

Estimates of the distribution of people in each age  and gender group is demonstrated as follows:  

Jersey Resident Population 2018 Estimate, SJ

In 2026, the projected population is 117,100, an overall increase of 12%. The proportion of those aged 65 or over is projected to increase from around 17% in 2018 to 19% in 2026.

Jersey Resident Population 2026 Estimate, SOJ

By 2036, the population increases by another 11%,  to 130,000.  

Around one in five (22%) of the population would  be aged 65 or over.  

Population Projections 2016-2036 PHSU, SOJ

Having a larger population of those aged 65 or over has implications for the health service, especially if these individuals have accumulated morbidities over their lifetime.

The projected increase in population size and change in its age profile will be reflected in an increase in GP consultations:

• It is estimated that there will be an additional 70,000 GP consultations each year by 2026, bringing the total to 502,000 (an increase of 16%)

• by 2036, it is estimated there will be an additional 143,000 consultations compared to 2016 (an increase of 33%) bringing the number of consultations to 575,000 per year[1]

Figures from the General Practitioner Central Server (GPCS) showed 105,490 people as registered with a Jersey GP and active on 31 December 2017. An analysis of the numbers of patients with 13 identified long-term conditions was conducted by Statistics Jersey, including the 12 long-term conditions recorded as part of the Jersey Quality Improvement Framework (JQIF) and cancer (with the exception of non-melanoma skin cancer).

Of people registered with a Jersey GP at the end of 2017, 75,020 (71%) had none of the 13 long-term conditions considered; 17,765 (17%) had a single long-term condition and 12,705 (12%) had two or more long- term conditions.

Progressively fewer patients had a higher number of the conditions:

• 17,765 (17% of all patients) had a single condition

• 7,545 (7%) 2 conditions

• 3,175 (3%) 3 conditions and

• 1,985 (2%) had 4 or more conditions.

Prevalence of health conditions in Jersey and their multi-morbidity, SJ 2018

The below graph shows the count and average age of Jersey GP patients with each type of morbidity (note: patients with multi-morbidity are linked to more than one condition)[2]:

By 2026 and 2036 there are significant  11Disease Projections 2016-2036, SJ 2016 projected increases in patient numbers

for many of these conditions11:

PREVENTION & PRIMARY CARE APPENDIX D: LONG-TERM CONDITIONS >>> Click here to return to Primary Care section

Minimising costly secondary care admissions though improved primary care management and self-care of long-term conditions, results in lower health costs and improved health outcomes. HCS has recognised the need to move management of long-term conditions into the community, with well-structured clinical pathways and handovers. Self-care and joint care planning (e.g. expert patient programme, patient education) should also play a significant role.

We will develop a Multidisciplinary Clinical Forum to manage and agree pathways across primary/secondary care, including (but not limited to) – Diabetes, COPD, Heart Failure, Depression, Epilepsy, End of Life Care. Pilots have been completed for Diabetes and COPD care, and this work now needs rapid expansion and roll- out.

Funding mechanisms as previously discussed will be required in order to transfer funds from secondary to primary care, considering a number of options (individually or in combination):

1. Bundled payments (for service user and HIF+/-HCS)
2. Expansion of JQIF quality measures to drive provider behaviour change
3. Funding a long-term conditions care co-ordinator role (expansion of year of care pilot areas)
4. Commissioning Framework

PREVENTION & PRIMARY CARE APPENDIX E: STRATEGIC AIMS – MORE DETAILS >>> Click here to return to Primary Care section

Improve health outcomes and improve population health – identifying disease earlier, and managing health and care better, means healthier, longer lives for the population.

Improve health system efficiency and health equity – minimising costly secondary care admissions though improved primary care management, particularly of long-term conditions, results in lower health costs. Supporting financially vulnerable, clinically vulnerable and socially vulnerable groups improves welfare and reduces overall costs.

Improve workforce utilisation with care closer to home – maximising use of appropriate primary-care and community resources releases capacity from specialist hospital resources, saving money and leading to improved satisfaction for all providers.

Support the island's economy – supporting an increasingly aging population to remain healthy and stay in work reduces the load on Social Security benefits, increases tax revenues, and ensures that the health and care system and wider economy are more sustainable.  

Self-care - develop and promote resources that help citizens with self-care for themselves, their families and  loved ones.  

Expand prevention and screening - increase access to safe, cost-effective screening services, in line with  international best practice, to identify and treat risk factors, pre-cursors and disease as early as possible.  

Improve access – for patients who are financially, clinically and socially vulnerable.  

Shift resources – staff and money – into preventative and primary care services and reduce reliance on secondary care services. Include community-based professionals (including GPs, pharmacists and others) in designing care pathways.

Intermediate care – urgently expand intermediate care services, both in terms of the types of services offered and the capacity of those services – deliver care as close to home as possible.

Support carers and the community – identify and implement opportunities to increase the support provided to carers with their own needs and those of the people they look after.

PREVENTION & PRIMARY CARE APPENDIX F: ENABLING THE STRATEGY >>> Click here to return to Primary Care section

DIGITAL CARE

In order for people to access services more efficiently Jersey's Primary Care System needs to be supported by a number of digital initiatives, aiming for Digital First' access in-line with Government of Jersey's CSP. Projects will include:

• Developing validated self-help resources

• Encouraging self-care/management via patient facing applications

• Monitoring of long-term conditions using IoT Devices

• Development of the Jersey Care Record – allowing access to appropriate information in different settings

• Widening access to booking appointments for patients and professionals, checking results, and exploring the use of video consultations and virtual wards

• Improving links with secondary care through: E-prescribing, E-discharge, GP Order comms

WORKFORCE PLANNING, EDUCATION AND TRAINING

The Primary Care strategy will be supported by the development of a Primary Care People Strategy, in-line with wider Health initiatives, to ensure we have the right people, with the right skills, in the right place, at the right time.

As a significant number of staff involved in the provision of prevention and primary care are not directly employed by Health & Community Services special consideration should be given as to how best address this issue.

We will move towards a collaborative approach to workforce planning, education and training which incorporates all primary and secondary care.

GOVERNANCE

Moving care from secondary to primary care will require expansion of primary care governance and assurance  structures, particularly if behaviour change is driven by expansion of JQIF. This needs to be explored and  costed.  

PREVENTION & PRIMARY CARE APPENDIX G: NOTES ON INTERMEDIATE CARE  

Improving care of long-term conditions will keep people healthy, their conditions stable, and reduce the need  for admission. However, when people do need more advance levels of care we plan to offer this care as close  to home as possible with expansion of the size and scope of our intermediate care offering, including:  

Expand our hospital-at-home/Rapid Response service  

• Prevent admission – care at home (IV therapy – antibiotics/diuretics), patient monitoring

• Faster discharge

• Expand team, capacity and skillset – more community nurse prescribers, expand service to new conditions; 24 hour community nursing

• Increase use of digital solutions to bring the hospital to the home

Utilise the island's non-acute bed-base: Acute hospital wards are not where patients should wait for a care package – improve flow to community facilities/nursing home beds/Silver Springs/home

Expand our re-enablement/frailty service

• Increase access to physiotherapy/occupational therapy/community exercise programmes

• Community geriatrician and multidisciplinary intermediate care team to facilitate standardised in-reach programmes

Primary Care will have a role to play in developing and delivering the specification for Intermediate Care.

PREVENTION & PRIMARY CARE APPENDIX H: CURRENT FUNDING SOURCES >>> Click here to return to Primary Care section

Health and Community Services - £209m (2018) funded by general taxation

Health Insurance Fund - £39.2m income, £31.9m expenditure (2017) funded from social security contributions

• Prescriptions £20m (£13m drugs, £7m dispensing fees)

• Pharmacy flu vaccines £0.1m

• GPs £8.8m (£6.9m medical benefit - £20.28/visit, £1.6m JQIF, £0.3m flu vaccines)

• £0.9m blood tests to Pathology, HCS

• Gluten free products £0.5m

• Admin £1.8m (inc. primary care governance, pharmaceutical advisors, CLS costs/processes, administration of law etc.)

JQIF

Medical  £1.6m

benefit pGlutrofrdeeuencts

£6.9m £0.5m

Pathology  Pharmaceutical benefit £6.9m

be£0.9mnefit HIF

£31.9m

GP HIF

contrac£0.3mts Drug costs

£13m

Pharmacy  Admin conHtraIF cts £1.8m

£0.1m

Patient payment – estimated contribution from the public for all General Practice Services is £10m

In 2017 a total of £36.1m was spent on Incapacity Benefits (LTIA, STIA, DB) – if we improve access to primary care and improve population health potential savings could be made, but more importantly there are significant benefits for society in general.

PREVENTION & PRIMARY CARE APPENDIX I: THE FUTURE OF FUNDING FOR PREVENTION AND PRIMARY CARE

>>> Click here to return to Primary Care section

Under the current state GoJ have only limited financial levers (JQIF) available to improve outcomes, drive care into the community, encourage self-care and achieve the aspirations of the Prevention and Primary Care Strategy. In order to frame the discussion around the future of funding for prevention and primary care there are three questions to be addressed and modelled.

1. WHATTOFUND? 

There are three approaches for consideration either in isolation or in combination.  

• Free general practice services[1] for all. The estimated contribution from the public for all general practice  services is £10m. Consideration could be given to replacing this contribution with central funding, making  general practice accessible to all.  

• Specific Primary Care services for specific groups  

- Financially vulnerable (those who are unable to afford the required GP consultations, either in the short or long term)

- Clinically vulnerable (dental care for children, long-term conditions, mental health conditions)

- Socially vulnerable (0-5y, all children, teenagers, elderly, vulnerable adults)

• Address specific inequalities/perverse incentives:

This refers to the current disparity in service user payments for similar services delivered in different environments. Resolving these inequities may help increase access in the shorter term. Some examples include – dressings and subsidised products, diabetes supplies, imaging & pathology, primary care presentations to ED

2. MECHANISMSFORPAYMENTANDWHOTOPAY?

There are several mechanisms for payments for provision of prevention and primary care services. Again, any solution is likely to incorporate part or all of each mechanism.

The below diagram illustrates how the widely used fee for service payment mechanism, with a low level of accountability and financial risk for the provider may lead to sub-optimal outcomes. Instead, the system should move towards payment mechanisms that create accountability and incentivise correct behaviours[2].

Value based payment continuum

3. WHATARETHESOURCESOFINCOME?

Funding for primary care services is currently provided from a combination of service user payments, payments from the Health Insurance Fund (HIF), and payments from Health and Community Services paid for  by general taxation)[3]. Increased provision of prevention and primary care services is likely to require extra  funding. This can be addressed in two ways:  

Reconfiguration of current funding streams  

• Moving funds and resources from secondary to primary care  

• Combination/redistribution of the HIF and HCS funding  

• Ring fenced budget for prevention & screening

Potential new funding streams

• Expand contributions from social security or general taxation

• Prescription charges

It should be noted that there is the potential to access funds from the HIF on a one off basis in order to offset double running costs in primary and secondary care during a period of transition.

PREVENTION & PRIMARY CARE APPENDIX J: PRIMARY CARE PHARMACISTS - EXAMPLE OF VALUE OPPORTUNITY

Pharmacist-led Information Technology Intervention for Medication Errors (PINCER)

PINCER involves using a computer programme to extract information from GP systems. Pharmacists use this information to identify patients at potential risk from their prescribed medicines. An action plan is then produced in conjunction with GP practice colleagues to carry out targeted reviews, resolve the issues identified and prevent future recurrence. Having a pharmacist available to identify the root cause of any prescribing problems, provide feedback, give educational outreach, and dedicated support for the GP practice makes a real differences to patient safety.

Potentially hazardous prescribing is identified by searching patient records for prescribing indicators'. An example of an indicator is;

Prescription of an oral non-steroidal anti-inflammatory drug (NSAID), without co-prescription of an ulcer healing drug, to a patient aged 65 years

The biggest impact in reduction in unsafe prescribing can be seen by indicators linked to a risk of gastrointestinal bleeding, heart failure, and kidney injury.

It is highly likely that PINCER will cut hospital admissions and would be a great way to meet the World Health Organization's Global Patient Safety Challenge of reducing the level of severe, avoidable harm related to medicines by 50% over the next five years.

By merging the PINCER indications with an electronic patient record, it is possible to develop a real-time health dashboard that flags up problems in a live' system rather than having to periodically run an audit.

The implementation of GP pharmacists is a vital part of making PINCER a success. Being able to access the information from GP systems is not enough the pharmacist is needed to make sense of the intervention, engage others and ensure changes are sustained in everyday practice.  

References  

Avery AJ, Rodgers S, Cantrill JA ET AL. A pharmacist-led information technology intervention for medication  errors (PINCER): a multicentre, cluster randomised, controlled trial and cost-effectiveness analysis. THE  LANCET 2012:9823;1310–1319. Available at; https://www.clinicalkey.com/#!/content/playContent/1-s2.0- S0140673611618175?returnurl=https:%2F%2Flinkinghub.elsevier.com%2Fretrieve%2Fpii%2FS0140673611618 175%3Fshowall%3Dtrue&referrer=https:%2F%2Fwww.pharmaceutical-journal.com%2Fnews-and- analysis%2Ffeatures%2Fthe-gp-pharmacists-leading-a-life-saving-medicines-safety- project%2F20206119.article%3FfirstPass%3Dfalse https://www.health.org.uk/improvement-projects/scale-up-replication-and-licensing-of-the-pincer- intervention

>>> Click here to return to Primary Care section

INTERMEDIATE CARE

INTERMEDIATE CARE APPENDIX A: INTERMEDIATE CARE SERVICE DEFINITION - HIGH LEVEL >>> Click here to return to Intermediate Care section

Key Service Attributes for Jersey

We will establish a Community Independence focussed Intermediate Care function which incorporates Frailty and Older Person's Rapid Access.

The service is proposed to run 7 days a week with a minimum 8am-8pm function but connected to a core overnight community function.

We expect the service to provide;

• Urgent Rapid Response (Nursing Assessment and Support - Intervention)

• Urgent Social Care Assessment & Support – Care direction

• Urgent Therapy Assessment & Support (Physio & or OT) – equipment and support

• Rapid deployment of Reablement support or enhanced care @ home

• Integrated liaison to the Mental Health Crisis Prevention Service

• Night sitting deployment

• Integrated Medical support to broaden the intermediate care scope

The service would be made up of Nurses, Social Workers, Therapists, Reablement workers, Mental Health staff and connected to but not driven by a medical model which incorporates Primary Care and Care of the Elderly specialist opinion.

The service would have rapid access to secondary care diagnostics, step up-down provision and home facing enabler services (handyman & parish based offer etc)

The service will be connected to a broader community services specification to support 24/7 care needs including end of life care. The service will work closely with the Closer to Home initiative.

This service will help support the changes in the social and long term care sector (residential & nursing) from bed based to home faced care provision around a personalisation agenda.

Key Expectations of the Service

• Improved Quality of care delivered in the right setting by the right professionals

• A reduction in admissions to the Acute sector for target groups (Ageing Demographics and Chronic conditions)

• Early facilitated discharge from the secondary care setting which improves LOS and drives a Discharge to Assess model

• A reduction in intensive & high cost packages of care

• A reduction in placement prevalence (Nursing and Residential)

• Reduced professional contacts & duplication as evidenced through PLICS

• Reduced Mental Health crisis activity

• Reduction in adverse safeguarding outcomes

• Reduction in interdisciplinary and inter-provider related incidents

• Improved service user experience and outcomes

NICE Definition (for reference)

Intermediate care is defined by NICE as follows; HCS would seek to develop a similar comprehensive offer tailored to Jersey needs.

Intermediate care

A range of integrated services that: promote faster recovery from illness; prevent unnecessary acute hospital  admissions and premature admissions to long-term care; support timely discharge from hospital; and  maximise independent living. Intermediate care services are usually delivered for no longer than 6 weeks and  often for as little as 1 to 2 weeks. Four service models of intermediate care are available: bed-based  intermediate care, crisis response, home-based intermediate care, and reablement.  

Bed-based intermediate care  

Assessment and interventions provided in a bed-based setting, such as an acute hospital, community hospital, residential care home, nursing home, stand-alone intermediate care facility, independent sector facility, Government facility or other bed-based setting. Bed-based intermediate care aims to prevent unnecessary admissions to acute hospitals and premature admissions to long-term care, and to support timely discharge from hospital. For most people, interventions last up to 6 weeks. Services are usually delivered by a multidisciplinary team but most commonly by healthcare professionals or care staff (in care homes).

Crisis response  

Community-based services provided to people in their own home or a care home. These services aim to avoid hospital admissions. Crisis response usually involves an assessment, and may provide short-term interventions (usually up to 48 hours). Crisis response is delivered by a multidisciplinary team but most commonly by healthcare professionals.

Home-based intermediate care

Community-based services that provide assessment and interventions to people in their own home or a care home. These services aim to prevent hospital admissions, support faster recovery from illness, support timely discharge from hospital, and maximise independent living. For most people interventions last up to 6 weeks. Services are delivered by a multidisciplinary team but most commonly by healthcare professionals or care staff (in care homes).

Home care

Care provided in a person's own home by paid care workers which helps them with their daily life. It is also known as domiciliary care. Home care workers are usually employed by an independent agency, and the service may be arranged by the local council or by the person receiving home care (or someone acting on their behalf).

Person-centred approach

An approach that puts the person at the centre of their support and goal planning. It is based around the person's strengths, needs, preferences and priorities. It involves treating them as an equal partner and  considering whether they may benefit from intermediate care, regardless of their living arrangements,  socioeconomic status or health conditions.  

Positive risk taking  

This involves balancing the positive benefits gained from taking risks against the negative effects of attempting  to avoid risk altogether.  

Reablement

Assessment and interventions provided to people in their home (or care home) aiming to help them recover skills and confidence and maximise their independence. For most people interventions last up to 6 weeks. Reablement is delivered by a multidisciplinary team but most commonly by social care practitioners.

Core principles of intermediate care, including reablement Ensure that intermediate care practitioners:

• develop goals in a collaborative way that optimises independence and wellbeing

• adopt a person-centred approach, taking into account cultural differences and preferences.

At all stages of assessment and delivery, ensure good communication between intermediate care practitioners and:

• other agencies

• people using the service and their families and carers.

Intermediate care practitioners should:

• work in partnership with the person to find out what they want to achieve and understand what motivates them

• focus on the person's own strengths and help them realise their potential to regain independence

• build the person's knowledge, skills, resilience and confidence

• learn to observe and guide and not automatically intervene, even when the person is struggling to perform an activity, such as dressing themselves or preparing a snack

• support positive risk taking.

Ensure that the person using intermediate care and their family and carers know who to speak to if they have any questions or concerns about the service, and how to contact them.

Offer the person the information they need to make decisions about their care and support, and to get the most out of the intermediate care service. Offer this information in a range of accessible formats, for example:

• verbally

• in written format (in plain English)  

• in other accessible formats, such as braille or Easy Read  

• translated into other languages  

• provided by a trained, qualified interpreter.