Proposed Government Plan 2023-2026 (P.97/2022): sixteenth amendment Multi-morbidity GP consultations

STATES OF JERSEY

PROPOSED GOVERNMENT PLAN 2023- 2026 (P.97/2022): SIXTEENTH AMENDMENT

MULTI-MORBIDITY GP CONSULTATIONS

Lodged au Greffe on 28th November 2022 by Deputy G.P. Southern of St. Helier Central Earliest date for debate: 13th December 2022

STATES GREFFE

2022  P.97 Amd.(16)

PROPOSED GOVERNMENT PLAN 2023-2026 (P.97/2022): SIXTEENTH AMENDMENT

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PAGE 2, PARAGRAPH (c) –

After the words "Appendix 2 – Summary Table 3 to the Report" insert the words –

", except that a new line should be inserted in Summary Table 3 to include a transfer of £6.5m from the Health Insurance Fund to the Consolidated Fund to allocate funds for the provision of a scheme to allow Islanders with multi- morbidity to receive G.P. consultations or other primary health interventions at a reduced rate of patient co-payment"

PAGE 2, PARAGRAPH (e) –

After the words "Appendix 2 – Summary Tables 5(i) and (ii) of the Report" insert the words –

 ", except that, in Summary Table 5(i) the Head of Expenditure for Health and Community Services should be increased by £6.5m to allocate funds for the provision of a scheme to allow Islanders with multi-morbidity to receive G.P. consultations or other primary health interventions at a reduced rate of patient co- payment"

Note:  After this amendment, the proposition would read as follows –

THE STATES are asked to decide whether they are of opinion

to receive the Government Plan 2023–2026 specified in Article 9(1) of the Public Finances (Jersey) Law 2019 ("the Law") and specifically –

1. to approve the estimate of total States income to be paid into the Consolidated Fund in 2023 as set out in Appendix 2 – Summary Table 1 to the Report, which is inclusive of the proposed taxation and impôts duties changes outlined in the Government Plan, in line with Article 9(2)(a) of the Law;
2. to  approve  the  proposed  Changes  to  Approval  for financing/borrowing for 2023, as shown in Appendix 2 – Summary Table 2 to the Report, which may be obtained by the Minister for Treasury and Resources, as and when required, in line with Article 9 (2)(c) of the Law, of up to those revised approvals;
3. to approve the transfers from one States fund to another for 2023 of up to and including the amounts set in Appendix 2 – Summary Table 3 in line with Article 9(2)(b) of the Law, except that a newline should be inserted in Summary Table 3 to include a transfer of£6.5m from the Health Insurance Fund to the Consolidated Fund to allocate funds for the provision of a scheme to allow Islanders with

multi-morbidity to receive G.P. consultations or other primary health interventions at a reduced rate of patient co-payment;

4. to approve each major project that is to be started or continued in 2023 and the total cost of each such project and any amendments to the proposed total cost of a major project under a previously approved Government Plan, in line with Article 9(2)(d), (e) and (f) of the Law and as set out in Appendix 2 - Summary Table 4 to the Report;
5. to  approve  the  proposed  amount  to  be  appropriated  from  the Consolidated Fund for 2023, for each Head of Expenditure, being gross  expenditure less estimated  income (if  any),  in  line  with Articles  9(2)(g),  10(1)  and  10(2)  of  the  Law,  and  set  out  in Appendix 2 – Summary Tables 5(i) and (ii) of the Report, exceptthat, in Summary Table 5(i) the Head of Expenditure for Health andCommunity Services should be increased by £6.5m to allocatefunds for the provision of a scheme to allow Islanders with multi- morbidity to receive G.P. consultations or other primary healthinterventions at a reduced rate of patient co-payment;
6. to approve the estimated income, being estimated gross income less expenditure, that each States trading operation will pay into its trading fund in 2023 in line with Article 9(2)(h) of the Law and set out in Appendix 2 – Summary Table 6 to the Report;
7. to approve the proposed amount to be appropriated from each States trading operation's trading fund for 2023 for each head of expenditure in line with Article 9(2)(i) of the Law and set out in Appendix 2 – Summary Table 7 to the Report;
8. to approve the estimated income and expenditure proposals for the Climate Emergency Fund for 2023 as set out in Appendix 2 – Summary Table 8 to the Report; and
9. to  approve,  in  accordance  with  Article  9(1)  of  the  Law,  the Government Plan 2023-2026, as set out at Appendix 3 to the Report.

REPORT

Following the adoption by the States of P.125/2019, as amended, the States has overseen the establishment of the Health Access Scheme (HAS) which has enabled affordable access to primary health care by some 11,000 of those on the lowest incomes and eligible for Income Support since January 2001. The success of the scheme, in reducing the patient co-payment from £50 (or more) to £12, removes one barrier to patients seeking early diagnosis and treatment, and possibly adopting healthier lifestyles earlier. This points the way to establishing sustainable funding for primary care in the medium to long term, as we are told will be established over the coming 2 years under the Jersey Care Model, currently subject to a "pause" for further analysis by health economists, and further study by the UK Government Actuaries which is due to report during the first half of 2023.

Members will recall that P.125 identified 3 groups who would benefit from reduced co- payments, namely those who are economically, clinically, or socially vulnerable. This amendment seeks to extend the range of the current Health Access Scheme in order to give affordable access to primary care for certain patients who are in clinical need. In a similar manner to the way that economic need can be easily focussed on without the need for extensive means testing (using the Income Support criteria), so we need to focus sharply on who has the greatest clinical need for support. Fortunately, this focus is already built into our primary care delivery system through the General Practitioner Central Server (GPCS) record of Morbidity.

Morbidity  is  the  state  of  having  a  long-term  (chronic)  medical  condition.  Multi- morbidity is defined as the presence of two or more long-term medical conditions in a patient.

Studies show that people with multiple chronic conditions (those with multi-morbidity) typically

- suffer a lower quality of life,

- have more frequent and lengthy hospital admissions, and

- may be more likely to die prematurely

 than those who do not have multi-morbidity.

The  latest  Multi-morbidity  report  (2021)  assesses  the  burden  of  multi-morbidity experienced by Jersey's population. It summarises the prevalence of certain long-term conditions amongst Jersey residents, as recorded by GPs. The analysis shows the prevalence of patients with more than one of these conditions (multi-morbidity), and which diseases are most commonly cooccurring.

Long-term conditions (morbidities)

There are 12 long-term conditions which form the basis of the multi-morbidity analysis presented. The Government of Jersey incentivises GPs to record patients with any of these long-term conditions through the Quality Improvement Framework (JQIF).

The 12 long-term morbidities are:

• Atrial Fibrillation (AF)  • Diabetes (DIA)

• Asthma (AST)  • Heart Failure (HF)

• Coronary Heart Disease (CHD)  • Hypertension (HYP)

• Chronic Kidney Disease (CKD)  •Mental Health Problems (MH)

• Chronic Obstructive Pulmonary Disease (COPD) • Obesity (OB)

• Stroke and Transient Ischemic Attack (STIA)   Dementia (DEM)

Patients with multiple morbidities

Of the 31,120 individuals who had at least one of the 12 long-term conditions as at the end of 2021:

• 18,215 individuals had a single long-term condition

• 12,905 individuals had two or more long-term conditions (multi-morbidity).

This means that approximately 12% of Jersey's overall population were living with multiple morbidities.

Of those individuals having two or more long-term conditions, progressively fewer had a higher number of long-term conditions:

• 7,690 individuals had two conditions, equivalent to 7% of the population

3,350 individuals had three conditions, equivalent to 3% of the population

• 1,865 individuals had four or more conditions, equivalent to 2% of the population

At the end of 2021, 12,905 individuals were found to have two or more long-term conditions (multi-morbidity) which means that approximately 12% of Jersey's overall population are living with multiple morbidities.

An individual with multi-morbidities is likely to require regular, if not frequent, visits to their G.P. to address their complex health needs. Furthermore a G.P. will have a key role  in  managing  the  health  of  individuals  with  multi-morbidities.  The  on-going financial burden of numerous G.P. visits can only serve to cause additional anxiety in an already stressful situation.

The fact is that, today, there are already many individuals who put off seeing their G.P., or simply refuse to seek treatment, because of the cost. This This undoubtedly results in higher treatment costs in the longer term as symptoms go untreated, diagnosis is delayed and the likelihood of hospital treatments increases.

It is to be noted that the Report on multi-morbidity states –

"Studies show that people with multiple chronic conditions (those with multi-morbidity) typically  suffer  a  lower  quality  of  life,  have  more  frequent  and  lengthy  hospital admissions, and may be more likely to die prematurely, than those who do not have multi-morbidity."

This amendment will not only alleviate the financial burden on individuals suffering with multi-morbidity by allowing access to GPs at a reduced rate but it will also minimise the burden on our healthcare system in the long term by increasing the early intervention of G.P.s (primary carers) thereby decreasing the amount of hospital-based secondary and tertiary care required.

If we are to meet the health care needs of what will be an increasingly ageing population, we must focus on those who have long-term morbidities. This basically means that we must deliver health care solutions for the elderly, who are the sector which will suffer from long-term conditions.

This proposition suggests that attention should be focussed on those with 2 or more morbidities, which in effect is those who are over 65.

Financial and manpower implications

Given the state of flux around the changes to the delivery of primary care and its financing, which may include the Health Insurance Fund ("HIF"), the HCS budget, capitation and quality payments, it is difficult to put a figure on the cost to the States of giving access to G.P. consultations at reduced cost to individuals with multi-morbidity especially since figures produced by Social Security create a distinction between a consultation and a service, however, if we say that each consultation was worth £60, multiplied by the number of patients known to have two or morbidities, and factoring an average 9 visits a year, this gives a cost in the order of £6.5m.