Common Strategic Policy (P.98/2022): third amendment

STATES OF JERSEY

COMMON STRATEGIC POLICY (P.98/2022): THIRD AMDENDMENT

Lodged au Greffe on 7th November 2022

by the Children, Education and Home Affairs Scrutiny Panel Earliest date for debate: 22nd November 2022

STATES GREFFE

COMMON STRATEGIC POLICY (P.98/2022): THIRD AMENDMENT

____________

PAGE 2 –

After the words "report of this Proposition" insert the words –

", except that on page 13, paragraph 6, before the words "We will invest also" there should be inserted the words –

"We will work towards providing free primary healthcare for all children in Jersey."

CHILDREN, EDUCATION AND HOME AFFAIRS SCRUTINY PANEL Note:  After this amendment, the proposition would read as follows –

THE STATES are asked to decide whether they are of opinion

in accordance with Article 18(2)(e) of the States of Jersey Law 2005, to approve the statement of the Common Strategic Policy of the Council of Ministers as set out in the report of this Proposition, except that on page 13, paragraph 6, before the words "We will invest also" there should be inserted the words –

"We will work towards providing free primary healthcare for all children in Jersey."

REPORT

Introduction

The statement of the Common Strategic Policy P.98/2022 (hereafter the CSP') was lodged by the Council of Ministers on 4th October 2022 and is due for debate by the States Assembly on 22nd November 2022. The CSP, if adopted by the States Assembly, will replace the CSP 2018-2022 and approve the Governments proposed seven Priorities for Change' (hereafter Priorities').

The CSP if adopted, would focus on the following Priorities over the next four years, with specific aims and key outcome indicators for each of the following–

• Community;

• Housing and Cost of Living;

• Economy and Skills;

• Children and Families;

• Ageing Population;

• Health and Wellbeing; and

• Environment.

The Children, Education and Home Affairs Scrutiny Panel (hereafter the Panel') has considered the Priorities of the CSP, in particular the Priority related to Children and Families', and the work undertaken by the Children's Commissioner on the 2022 Jersey Youth Manifesto (hereafter the Manifesto').

The Panel notes Point 4 of the Manifesto, which states:

"Help when we need it: Getting help shouldn't come at a cost – we shouldn't have to choose between paying a doctor or paying for food, and we shouldn't have to queue for help if we're in an emotional or mental health crisis"

The Panel is supportive of primary healthcare that's accessible to all children in Jersey and has agreed that an amendment to the CSP should be made following its own research and consultation with key stakeholders. The Panel's amendment requests that the Government should work towards the principle of free primary healthcare for all children in Jersey'.

To help inform the amendment, the Panel undertook its own research and decided to write to key stakeholders to collect feedback about the CSP in relation to children's access to primary healthcare in Jersey. Due to the short timeframe available to present an amendment to the CSP, the Panel did not receive responses to all of its correspondence, however, received and considered responses from the Primary Care Body, the Children's Commissioner, Family Nursing and Home Care, the Minister for Health and Social Services, the Minister for Social Security and the Minister for Children and Education. [1]

Health inequalities and access to primary healthcare

Health inequalities have been defined as "avoidable, unfair and systematic differences in health between different groups of people".2 The Panel understands that health

inequalities do exist in Jersey and have a material impact on the health outcomes of children. For example, a consultation undertaken by the Government of Jersey in 2021 on the development of the Public Health Law, highlighted that there were differences in levels of childhood obesity that depended on where children lived in Jersey and whether they attended a fee-paying or non-fee-paying school.3

The Panel wishes to highlight the relationship between health inequalities and access to primary healthcare. This is because child health outcomes can be affected by a range of socioeconomic factors:

"When health inequalities are mapped across a population it highlights that not only do the poorest people have the poorest health. The richest people are slightly healthier than the second richest people, who are in turn slightly healthier than the third richest, etc. Social inequalities in health are therefore a matter of concern for all of us."4

In a submission provided by the Minister for Health and Social Services, the Panel noted evidence that showed a higher proportion of children that attended the Emergency Department between 2019 and 2022 were triaged as non-emergency, when compared with adults:

However, the Panel notes that the data may be a result of a number of factors driving a higher level of non-emergency attendance amongst children, including parents natural caution when a child is unwell.5

The Panel is supportive of the Government's commitment in the CSP under the Health and Wellbeing' Priority to "reduce health inequalities for all improving health and care outcomes".  The  Panel  also  wishes  to  highlight  the  Jersey  Health  and  Wellbeing Framework developed in 2019, which committed to understanding where inequalities

2 What are Health inequalities?' – The Kings Fund is an independent charitable organisation working to improve health and care in England.

3 Ibid

4 Ibid

5 Minister for Health and Social Services – Submission

may exist, and what the causes are so that they can be addressed, in line with other developed nations such as the United Kingdom, Canada, Australia and Norway.[2]

The importance of primary healthcare

The Panel understands that whilst general practice provides most of the medical care to children and young people, it is also provided by health visitors, school nurses, dentists, pharmacists, physiotherapists, and other allied health professionals.[3] The Panel recognises the importance of access to primary healthcare and notes five ways that primary healthcare is valuable to children and adults alike:

1. "It provides a place to which patients can bring a wide range of health problems for appropriate attentiona place in which patients can expect, in most instances, that their problems will be resolved without referral.
2. It guides patients through the health system, including appropriate referrals for services from other health professionals.
3. It facilitates an ongoing relationship between patients and clinicians and fosters participation by patients in decision making about their health and their own care.
4. It provides opportunities for disease prevention and health promotion as well as early detection of problems.
5. It helps build bridges between personal health care services and patients' families and communities that can assist in meeting the health needs of the patient."[4]

The cost of primary healthcare

The Panel is supportive of the Government's commitment in the CSP to make decisions that have regard to the affordability and accessibility of healthcare.

The Panel believes that cost is an important factor affecting children's access to primary healthcare services, and a factor contributing to child health inequalities in Jersey and forms the basis for the Panel's amendment to the CSP. This is because the Panel has considered  data,  as  well  as  feedback  from  children  and  young  people,  about  the relationship between cost and the accessibility of primary healthcare services in Jersey. For example, the Jersey Performance Framework collected data in 2017 that found that 18% of households with children felt that the cost of GP appointments for children stopped them seeing a GP at least sometimes.[5]

Furthermore, the Panel recognises that the cost of primary healthcare can be a source of worry and concern for children themselves. This is demonstrated by the Life on the Rock' Report (hereafter the Report) published by the Children's Commissioner, which highlighted that 48% of children that took park in a 2018 survey felt that "Making it free to go to the doctor if you're not well",[6]was one of the top five things that would make Jersey better for young people.

The Panel also considered some of the key messages from the Children's Advisory Group, published in the Report, about the relationship between primary healthcare costs and accessibility, these included:

"Limited medical, dental and mental health services, coupled with money worries and long waiting times, affect children's access to the healthcare they need"

"Life in Jersey would be much better for children and young people if doctors, dentists and other healthcare costs were free for those under 18 years. Paying these costs can affect some families being able to access medical help when they need it. This is not fair, as children do not have their own money and it is not their fault if their parents cannot pay."

"It is very worrying that some people resist going to the doctor until they absolutely have too - a life-or-death situation'. This means people could be living with illnesses for longer than they need to, or some illnesses could be more serious than first thought. Being sick for long periods can mean time spent off school, which affects children's learning."11

The Panel believes it is important that children's worries about their own health are addressed through access to primary healthcare services. This is because the Panel has identified data that demonstrates a proportion of school age children are worried about their health on most days. The results of the Jersey Children and Young People's Survey (hereafter Survey') published in 2019 by Statistics Jersey, found that 8% of children in the Year 4 and Year 6 school age groups worried about health problems on most days. The Panel acknowledges that this is a low percentage of children in the Year 4 and Year 6 age groups but is concerned about children that regularly worry about their health.

The Survey also revealed the percentage of children in the Year 8, 10 and 12 age groups that worried about their physical and emotional health on most days, as demonstrated by the following table:12

In a submission to the Panel, it was outlined that historically the Office of the Children's Commissioner would only consider Jersey's obligations under Article 24 of the United Nations Convention on the Rights of the Child13 to be met, once all healthcare in Jersey was made free for all children and young people. However, it was recognised that the progression of children's rights in Jersey was a process that could take time:

11 Life on the Rock' Report – Children's Commissioner

12 Jersey Children and Young People's Survey Report – 2019 13 United Nations Convention on the Rights of the Child

"Article 24 of the United Nations Convention on the Rights of the Child, which was adopted by Jersey in 2014, states that every child has the right to the best possible healthcare. With that in mind, the position of our office has historically been, and continues to be, that Jersey's obligations under Article 24 will only have been fully met when all healthcare is free for all children and young people under the age of 18. However, the realisation of children's rights is progressive, and objectives cannot always be achieved in one fell swoop."[7]

The Panel recognises that Government initiatives such as the Health Access Scheme do provide free GP surgery and telephone consultations for children and young people aged 16 years of age and under. However, the Health Access Scheme is only available to children that are members of an Income Support household.

It was submitted to the Panel by the Minister for Health and Social Services, that the Government currently supports standard fees for eligible adults and children under the Health Access Scheme, with all 14 general practices participating.

The Panel notes that as of 1st November 2022, a total of 2,642 children and young people up to the age of 17 are eligible for the Health Access Scheme. The Panel asked the Minister for Social Security how many children were not eligible and was advised that:

"Comparing the number of children who were members of Income Support households and included in the Health Access Scheme at the time of the 2021 census, with Census population numbers – approximately 14,000 children and young people do not access care under the scheme"[8]

The Panel understands that other areas of primary healthcare access for children are affected by cost too. The 2021 Jersey Children and Young People's Survey highlighted that overall, 20% of children and young people reported not having visited a dentist within the last year, and that the Dental Fitness Scheme was introduced to improve access to dental treatment for children from low-income households.[9]

Sustainable funding of primary healthcare costs

If the States Assembly chooses to adopt this amendment to the CSP, it will require Government to develop a sustainable model of funding.

The Panel believes it is important that Government considers funding options that ensure the amendment is financially sustainable in the long-term. This is because the current arrangements affecting, GP surgery consultations for example, produce a funding shortfall that requires patients to cover the remainder of the consultation fee amount after the Health Insurance Fund subsidy has been applied. This position can be compared with examples in other jurisdictions, such as the Swedish healthcare system, which is publicly financed based on local taxation. In Sweden, all healthcare for children and adolescents is free of charge up to 18 years of age.[10]

However, the Panel also believes that the amendment must be considered in relation to the potential wider impact on general practice and other patient groups that need access

to  primary  healthcare  services.  This  is  because  the  Panel  does  not  wish  for  the amendment  to  have  unintended  consequences  for  other  patient  groups,  as  was represented by the Primary Care Body Board in its submission to the Panel.

In  addition,  the  Panel  believes  that  the  amendment  must  be  developed  with consideration for the potential impact on demand for primary care services. This is because there is some evidence that the introduction of free primary healthcare schemes for children in other jurisdictions can, as a consequence, result in an increase in demand for primary care services. 18

Conclusion

The Panel would urge Members to support this amendment to the CSP which will require Government to work towards the principle of removing cost barriers that prevent some children from accessing primary healthcare services in Jersey, and to do so with the development of a financially sustainable model of funding.

Financial and manpower implications

This amendment requests that the Government commits to the principle of free-primary healthcare for children and young people as part of its CSP. The resulting costs of the proposed amendment to the CSP is not known at this stage, and it is for the Government to establish and investigate what those costs would be as part of its work to review the sustainable funding as part of the primary care strategy.

18 Children's visits to doctor soared after free care introduced, as medics call for more GPs – The (Irish) Independent