Health and Social Services Organisational and Management Improvement Plan.

This report has been prepared by:

The Chief Executive and the Corporate Executive Directors of the Health and Social Services Department.

 December 2010

For further information contact: Health & Social Services Department, Headquarters, 4th Floor, Peter Crill House, Gloucester Street, St Helier, JE1 3QS

0. CONTEXT

1. EXECUTIVE SUMMARY

In order that it can ensure the provision of safe, effective and value for money services, the Department must function as a "fit for purpose" business within the States of Jersey. It must be able to evidence and operate efficient and effective systems and processes of corporate, clinical and financial governance. This Plan sets out the actions already taken and those that are programmed to be delivered during 2011 that will further strengthen the structures, systems and processes that underpin the operation of a well governed, fit for purpose, States Department. It should be noted that, some actions can only be delivered by the acquisition of additional capacity and skill sets and, at this point in time, those resources have yet to be identified.

The  Department  is  now  at  a  critical  juncture,  where,  having  absorbed  and  reacted  to  the recommendations made as a result of the independent external reviews by Williamson and Verita, it now needs to move on. It is welcome, therefore, to read the positive endorsement by Verita on the progress  made  since  they  conducted  their  review,  during  their  recent  re-visit  to  review  the implementation of their recommendations they commented on how impressed they have been by the changes they have observed and that it is clear that significant progress has been made on a wide range of fronts.

In their recent inspection report they also note:

 "We would be among the first to recognise that the hospital has long comprised of dedicated, talented and skilled individuals, providing high quality care and safe patient care. This remains the case today"

Building on this platform, the Department's Corporate Management Executive has recognised the need for reform, of both the organisation and the services it delivers, in fundamental ways if we are to meet the challenges faced, whether posed by a new economic reality, the demands of an aging population or the need to develop a more sustainable workforce model. Change on this scale requires effective partnerships with our staff, the commercial and voluntary sectors, other States Departments, politicians and members of the public. In addition, as the steward of a considerable amount of tax payer's money and the employer of some 3000 local residents, the Department must function in a business-like manner ensuring "fit for purpose" corporate, clinical and financial governance.

Our work over the last six months, and our proposals for 2011, are set out in the following chapters of this report.

Julie Garbutt Chief Executive

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2. STRATEGIC CONTEXT

Health and Social Care has to provide a full range of services 24/7, 365 days a year. Delivering this to a relatively small population will always pose difficulties in achieving sufficient economies of scale to make this as efficient as it would be for a larger organisation in the UK. Whilst good quality patient and client care are the overriding imperatives the delivery of efficient services, and the good stewardship of public monies, are also key objectives for the Department.

Jersey faces many challenges, not least agreeing a clear strategic direction for how health and social care will be provided in the future. The Island has not maintained parity of investment with other European and North American Jurisdictions in respect of its health and social care facilities. The differential on pay and conditions of service which Jersey has traditionally enjoyed has also narrowed with pay modernisation in the NHS. It is now harder to compete with and attract doctors, qualified nurses and social workers in a global economy where demands for these skill sets has increased as the population for all western economies ages.

Jersey also has an aging population and it is well established that demand for health and social care services towards the end of life increase dramatically. Health technologies have improved significantly over the last 20 years, with treatments which can considerably extend life expectancy in conditions which once would have resulted in death. These treatments and new technologies come at a price, and required skilled staff to deliver them.

The Department needs to become more efficient to support increased demand on its services without necessarily  consuming  a  proportionately  greater  amount  of  resources.  However  to  meet  rising expectations from the public and provide care in appropriate settings will require investment. Managing this change will also require effective, appropriately skilled leaders, a well motivated and engaged workforce and efficient business systems and processes.

3. FITNESS FOR PURPOSE

This section provides an initial assessment of the fitness for purpose of the organisational design and capability of the business to manage successfully in this new environment.

The inherited senior management arrangements for the Department in June 2010 involved 14 direct reports to the Chief Executive. The corporate and clinical governance systems were also found to be underdeveloped, meaning that performance and service risks in key parts of the business were neither as corporately owned nor as effectively managed as might be expected.

Weaknesses in the architecture and systems for managing the business had been highlighted in both the Verita Report and a near contemporaneous report by Price waterhouseCoopers, commissioned by the Comptroller and Auditor General in 2009.

Given the scale of the changes which were required in the Department, management capacity was also under developed and inappropriately targeted to address these urgent priorities. In seeking to address this, the Department reviewed its corporate, clinical and financial governance arrangements so as to be able to strengthen these moving forward. Improvements were sought in the following key areas:

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No.

Action

Lead

Target Completion Date (month, year)

1.

Appointing an experienced Managing Director for the Hospital and putting in place a turnaround plan to reduce unsustainable overspends.

Chief Executive

May 2010 COMPLETED

2.

Establishing a new Corporate Management Executive (CMEX) to improve corporate and performance management across the business with a renewed focus on key strategic and operational priorities.

Chief Executive

July 2010 COMPLETED

3.

Assigning specific responsibilities for both corporate and clinical governance development to named directors.

Chief Executive

July 2010 COMPLETED

4.

Reducing the number of direct reports to the Chief Executive to provide a more effective management span of control.

Chief Executive

July 2010 COMPLETED

5.

Bringing together adult, children's and mental health services into a new directorate of Community and Social Services and appointing an experienced ex- director of social services to lead the integration of these services and the establishment of this new directorate.

Chief Executive

September 2010 COMPLETED

6.

Securing greater clinical engagement in managing the business, not least through the appointment of new Joint Medical Directors tasked to develop key areas of clinical leadership.

Chief Executive

Managing Director Hospital

November 2010 COMPLETED

7.

Enhancing clinical governance in the hospital through appointment to suitable senior clinical leadership roles.

Managing Director Hospital

November 2010 COMPLETED

8.

Developing a revised scheme of financial delegation for budget holders.

Director of Finance & Information

December 2010 COMPLETED

9.

Securing additional capacity in critical functional areas of the business, such as Human Resources.

Chief Executive States Director of Human Resources

December 2010 COMPLETED

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0. IMPROVEMENT ACTIONS

1. FOCUS ON CORPORATE AND CLINICAL GOVERNANCE

This  section  looks  at  the  process  of  creating  the  right  governance  arrangements  for  effectively managing a complex integrated health and social care business with a commissioning, regulatory and delivery agenda for the Island. It highlights the creation of CMEX, the Ministerial Advisory Panel and the management  restructuring  as  well  as  concrete  steps  taken  to  deliver  cost  savings.  Critical appointments  into  senior  leadership  roles  have  been  made  with  emphasis  given  to  clear accountabilities, improved risk management and an appropriate scheme of delegation to increase staff involvement.

Whilst  much  has  been  achieved  in  the  development  of  the  Corporate  and  Clinical  Governance frameworks across health and social services, an opportunity has presented itself to strengthen this work further as the organisation is restructured.

Part of the restructuring includes the formation of key committees and groups that will support the corporate,  clinical  and  financial  governance  framework  through  improved  reporting  and  increased accountability. The development of a Ministerial Advisory Panel will provide the Minister and Assistant Ministers with independent expert advice regarding best practice in relation to health and social care delivery in the Island.

In addition to this the restoration of senior leadership roles provides clarity in relation to accountability and responsibility for service delivery across the key operational departments of Community and Social Services and the General Hospital.

It is important to ensure that throughout the restructuring the department continues to operate an effective system of internal control, and is able to demonstrate that principal risks to the achievement of the organisation's objectives are being managed and addressed. In order to strengthen the current and revised arrangements a number of key actions have been taken or are now required as set out below. These include identifying principal clinical and corporate risks and ensuring that timely and appropriate mitigating actions are put in place. In terms of assurance on delivery of the actions points, this will be monitored through the Integrated Governance Committee of HSSD.

No.

Action

Lead

Target Completion Date (month, year)

1.

Implementation of an Assurance Framework through the Integrated Governance Committee.

Chief Nurse

 October 2010 COMPLETED

2.

Development of revised corporate structure charts for the organisation.

Director of Human Resources

December 2010 COMPLETED

3.

Establish Care Quality Groups for both the Hospital and Community & Social Services.

Managing Directors of the Hospital and Community and Social Services

December 2010 COMPLETED

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4.

Publication of Corporate Committee Structure within HSSD providing clear reporting lines and accountability for decision-making.

Deputy Chief Executive and Chief Nurse

December 2010

COMPLETED

5.

Development of HSSD Risk Management Framework that encompasses all components of integrated governance.

Chief Nurse

December 2010 COMPLETED

6.

Establishment of a single comprehensive risk register incorporating clinical and corporate risks. This will assign clear ownership for the risk and appropriate mitigation or control actions.

Chief Nurse

February 2011

7.

Develop external assurance by establishing clear memoranda of understanding or service agreements with outside regulatory bodies i.e. Nursing & Midwifery Council (NMC), Social Work Inspection Agency (SWIA).

Deputy Chief Executive Chief Nurse

March 2011

8.

Establishment of a Ministerial Advisory Panel to provide independent advice to the Minister of Health & Social Services.

Deputy Chief Executive

March 2011

9.

Development of a clinical audit strategy to include an annual audit programme, Multi- disciplinary team clinical audit days and the introduction of morbidity-mortality meetings twice yearly.

Associate Medical Director Governance

March 2011

10.

Development of strengthened governance arrangements within Community & Social Services.

Managing Director Community and Social Services

June 2011

11.

Development of strengthened governance arrangements within the Hospital.

Managing Director Hospital

June 2011

12.

Review operation of Independent second stage complaints procedure.

Deputy Chief Executive

 July 2011

13.

Child Protection Inspection with SWIA completed.

Deputy Chief Executive and Managing Director Community & Social Services

November 2011

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14.

Roll out of Jersey Induction and Mandatory training Academy incorporating a locum doctor electronic screening tool.

Associate Medical Director Governance

December 2011

2.2 FOCUS ON MANAGEMENT CAPACITY AND CAPABILITY

An effective Health and Social Services Department requires appropriate organisational arrangements and management capacity to ensure that safe and effective care is delivered. The Department has many managerial functions it must discharge including a planning and commissioning role, regulatory responsibilities and governance, health protection and delivery of services in hospital and community based settings. This section looks at the key delivery capabilities the Department requires moving forward.

Corporate Management & Management Capacity

All  organisations  require  effective  leadership  and  co-ordination  between  the  various  delivery  and corporate  support  functions.  A  new  Corporate  Management  Executive  (CMEX)  with  a  consistent management and clinical membership was established in July 2010. The previous Senior Management Team structure was not ideal in creating a common purpose with a varying membership and a large span  of  control  for  the  Chief  Executive.  A  conscious  effort  has  been  made  to  improve  clinical engagement with the management of the organisation following the appointment of the joint Medical Directors and involvement of GPs to provide a primary care perspective.

The  Corporate  Management  Executive  will  need  to  progressively  improve  the  performance  and benchmarking information available so as to manage the delivery of safe and good quality care more effectively.  A  new  Assurance  Framework  has  been  developed  and  this  must  be  supported  by investment in the necessary analytical skills. Good governance is also about good management and having sufficient managerial capacity and skills to support the Department's change agenda.

Programme and Project Management

New skills are also required to deliver modern public services and particularly to deliver the scale of change  which  will  be  required  in  redesigning  health  and  social  care  in  the  future.  Programme management involves the delivery of effective change on time and to budget, whether this is a product such as an IT system, a new service development or a new way of working. In common with many complex  organisations,  the  Department  needs  to  improve  its  programme  and  risk  management capability. A new Programme Management Office has been established to oversee and help support delivery  of  the  portfolio  of  change  programmes  across  the  organisation.  However,  this  requires additional capacity to become fully functional. This will be critical to the successful delivery of the CSR plans and reform for health and social services.

Modern Corporate Services

Health and social care delivery requires effective support in areas such as finance, human resources and information systems. In each of these areas the Department has initiated reforms to improve the effectiveness of these services to better align them with the needs of business units in the Hospital,

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Community & Social Services and Public Health. The Department is also working closely with the States  Treasurer,  Chief  Information  Officer  and  States  Director  of  Human  Resources  on  their programmes to deliver modern, effective corporate services.

Commissioning

In line with the recommendations of the Verita and Williamson Reports, there has been a strengthening of the leadership and management capacity in the Hospital and Community and Social Services directorate. Coupled with this is a clearer devolvement of accountability and responsibility for service delivery, financial management and governance. At the same time, there is a need to strengthen the ability of the corporate centre to hold these delivery units to account for their performance and implementation of appropriate strategic plans for change as they emerge from the Strategic Roadmap work during 2011. As a result, a Director of Commissioning will be recruited by summer 2011. This will ensure that commissioning skills are brought into the department to oversee the transformation of services as set out in the Roadmap. Given the likely need to develop non-hospital services in primary and community care settings, some additional commissioning expertise in these areas will also be required.

No.

Action

Lead

Target Completion Date (month, year)

1.

Appointment of Interim Managing Director for the Hospital.

Appointment of Substantive postholder.

Chief Executive

May 2010

COMPLETED December 2010

2.

Appointment of Interim Director of Human Resources.

Appointment of Substantive postholder – some additional resource required to secure the skill set required.  

Chief Executive and States Director of Human Resources

May 2010 COMPLETED June 2011

3.

Development of new Corporate Management Executive and subcommittee structures to provide more effective management to the organisation.

Chief Executive

July 2010 COMPLETED

4.

Establishment of a CSR Delivery Programme and Programme Management Office – additional resource required for effective functioning.

Chief Executive

Deputy Chief Executive

September 2010 COMPLETED

5.

Appointment of joint Medical Directors.

Chief Executive and Managing Director Hospital

October 2010 COMPLETED

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6.

Appointment of permanent Managing Director Community and Social Services.

Chief Executive

November 2010 COMPLETED

7.

Development of revised management and organisational structures for the Hospital, Community & Social Services and Public Health Directorates.

There are some key additional skill sets and capacity required, particularly in the Hospital but also in mental  health services, that require additional resources that are not yet available

Managing Director Hospital

Managing Director Community & Social Services

Medical Officer of Health

February 2011

8.

Design and delivery of a series of Risk Management workshops to support the effective embedding of risk management practices across the organisation.

Director of Human Resources

Chief Nurse

February 2011

9.

Develop a series of Delivery Skills workshops for managers and clinicians involved in delivering service changes.

Director of Human Resources

March 2011

10.

Appointment of a Director of Commissioning/commissioning team.  Additional resources will be required  

Chief Executive

July 2011

2.3 FOCUS ON MANAGEMENT INFORMATION SYSTEMS

This section considers the critical information development requirements to effectively manage the business through the rigorous use of key tools and measures including; a Performance Scorecard, Hospital Standardised Mortality Ratios (HSMRs), Length of Stay, the introduction of Service Line Reporting, Workforce Plan/Scorecard, and more generally acknowledging how the IS Strategy may need to develop to meet the needs of a 21st Century workplace.

The Health and Social Services Department has for many years lacked complete information relating to clinical activities to support management decision making. The effect of this is that Health and Social services is, in this regard, considerably behind comparable UK organisations.

This section considers the development of core systems and the necessary support teams to ensure appropriate information is captured and made readily available to support management and clinical decisions.

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Technical Team (The H&SS IS Business Support Group)

Considerable hardware upgrades for H&SS core systems have been undertaken as part of the ICR (Integrated Care Record) project. The H&SS IS Business Support Group (BSG) is the team that provides  administration,  technical  and  user  support  in  respect  of  H&SS  hardware  and  software applications. In conjunction with the States of Jersey Head of IS, the future options for the optimal management of the IS Business Support Group have been considered.

As part of this, the management structure will need to be re-designed to better reflect the service needs of the Department. A proposal to provide a transitional solution is being developing in collaboration with the Chief Minister's Department to change the way user support is provided for Health & Social Services IS systems.

Continued Development and Integration of H&SS clinical systems

The  Integrated  Care  Record  (ICR)  provided  a  vision  for  creating  a  single  patient  record  that encompassed all aspects of the patient's care. However, this vision ultimately proved too costly to deliver  and  whilst  the  platform  for  the  ICR  is  being  implemented,  the  scope  of  the  project  was considerably revised in 2009. The Patient Administration System (PAS) was planned to come on line at the end of 2010 and this has now been rescheduled for the end of summer 2011.

The revised go-live date is to help mitigate the clinical risks of implementing a new clinical system in the winter period where activities and priorities can change rapidly e.g. due to serious flu outbreak, extreme cold weather generating an increase in hospital admissions due to slips, traffic accidents and chest conditions etc. To move towards the long term vision of an ICR, several individual projects will be scoped based upon clinical opportunities where the benefits delivered will help generate the revenue required to meet the ongoing costs.

Development of a Dedicated Management Information Team

An effective Health & Social Services Department requires appropriately analysed information to enable effective management decision making and the monitoring of organisational performance. The current systems  and  technical  support  available  to  enable  this  information  to  be  captured  and  analysed requires a dedicated team with appropriate skill levels.

The information team will be focused to deliver corporate information on performance management, clinical effectiveness and strategic planning. This team will be fundamental in providing clinical activity information for the balanced score card, corporate performance indicators and to support performance management of the business. It will also be critical to the development, over time, of Service Level Reporting  (SLR),  Patient  Level  Information  Costing  (PLICs),  and  the  development  of  island  wide capacity plans to improve management of waiting lists.

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2.5 FOCUS ON FINANCE

This section considers the finance and related information systems required to support a complex and unique  organisation  that  spans  many  varied  areas  of  activity.  It  focuses  on  improving  financial management and control (adherence to Financial Directions etc.) and developing appropriate financial information to support clinical activities, strategic planning and building procurement capability.

Scheme of Delegation and Basic Resource Accountabilities

The legacy management structure in the department has been restructured to better support the appropriate delegation of authority for budgets. In addition, clear accountabilities and reporting lines in the revised management structure have been introduced in the Hospital and in Community and Social Services.

An appropriate scheme of delegation is being established with budget holders clearly identified, trained and held accountable for resources under their control. The finance team will be able to provide better support to the reduced number of budget holders in the Department, making use of the Really Real Time (RRT) reporting tool.

Alignment of Financial Resources to Service Outputs, Benchmarking, Demonstration of VFM and appropriate Service Reporting

The  management  restructure  and  scheme  of  delegation  are  fundamental  in  ensuring  that  the Accounting  Officer  has  a  clear  hierarchy  of  accountability  for  the  total  resources  voted  to  the Department.

The next stage will be to ensure that all business units and financial resources are appropriately aligned to  the  delivery  of  agreed  service  outputs.  Corporate  support  and  overhead  costs  will  then  be apportioned to service areas on a monthly basis. The full cost of services will, thereafter, be monitored on a monthly basis, with a clear understanding as to the responsibility of corporate directors for the management  of  resources  within  their  control. This  is  called  Service  Line  Reporting  (SLR)  and effectively means that the Department will, moving forward, be able to fully articulate the actual cost of delivering any service on a monthly basis.

The benefit of structuring the Department in this way is that costs can then be benchmarked against UK Health and Social Care providers, helping to identify and control the key cost drivers. The Department will be in a better position to justify the additional costs i.e. diseconomies of scale operating in a small Island jurisdiction or target management action to reduce any source of in-efficiency.

Financial Control Environment, Polices and Procedures, compliance with financial Directions and Budget Holder Training

The  Department  is  further  strengthening  the  internal  control  environment  to  demonstrate  good stewardship and improve value for money. A considerable number of procedure documents have been developed to support budget holders in following H&SS Finance Polices and Financial Directions.  

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No.

Action

Lead

Target Completion Date (month, year)

1.

Review range of functions provided within the Public Health Department in the context of the establishment of the new Community and Social Services Directorate

Medical Officer of

Health and Managing Director of Community

and Social Services

March 2011

2.

Increased joint working with Guernsey and Planning & Environment in relation to Health Protection.

Medical Officer of Health, Guernsey Health Authorities and Planning and Environment, Jersey

April 2011

2.7 FOCUS ON ESTATES AND ACCOMMODATION

This section looks at the workspace and accommodation requirements for a modern 21st Century health and social care environment

Investment in Facilities

It is evident that there has been insufficient investment in the estate across Health and Social Services since the last major development at the General Hospital in 1987. Since then some investment has been made in service areas that include Day Surgery, ENT, Eyes, Radiology, A&E, within the hospital, Greenfields and the Assessment and Rehabilitation Centre at Overdale. The rest of the vast estate has been slowly deteriorating with ever reducing building maintenance and investment funding and the estate has fallen significantly behind the standard now generally expected in other jurisdictions.

Mitigation and Building Replacement Strategy

Short  term  actions  to  mitigate  potential  key  estate  risks  have  been  identified  in  advance  of implementation of the longer term solution (rebuilding or relocating of the Hospital and other facilities including mental health and social care facilities).

Strategies have been identified which will support the reduction of what are considered the highest risks. These will, where possible, identify older buildings that can be disposed of to generate capital funding for re-investing into bespoke modern and fit for purpose accommodation.

In order to advance these strategies, Health and Social Services is working closely with Property Holdings to identify which buildings would be best disposed of, their value and the required funding to rebuild.

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2.8 FOCUS ON CULTURE AND COMMUNICATIONS

The Health and Social Services Department has the largest workforce in the States of Jersey. Staff work across more than 200 sites and deliver care 24/7, 365 days of the year. This makes for a uniquely challenging set of circumstances in which to communicate and engage with people. The organisation is going through a period of significant organisational and service changes, together with a programme of reforms to help deliver the Comprehensive Spending Review (CSR) savings agreed for the Department

Supporting Staff Engagement

Health and social care have many stakeholders with a legitimate interest in how services are managed and they will develop. Until recently the Department had no dedicated resource to help manage internal communications  or  proactively  manage  media  communications.  In  November  2010  a  full  time communications  professional  was  appointed.  A  Staff  Engagement  &  Communication  Plan  was developed to help involve staff in the changes which were being implemented as part of the CSR. To build on this a Partnership Forum was established with staff representatives and members of the Corporate  Management  Executive  chaired  by  the  Chief  Executive.  A  programme  of  CSR  Staff Workshops was initiated in November to engage staff from all professional groups and at each of our main locations on the need for change and seek their ideas on doing things differently to support the Department's savings goals.

Building an Open Culture

The importance of openness in a health and social care setting is critical to ensure safe services to patients and clients. We need to capitalise on the potential advantages of an integrated service by breaking down unnecessary barriers between and across professional groups.

Health and Social Services have a highly educated professional workforce who expect to be involved in, and consulted on, changes which affect them and their services. Staff working on the front line are also the people who often know ways to improve how their service is delivered, if they are empowered to do so. Whilst developing a new culture takes many years, the Department has started to build the necessary foundations for this new way of working.

No.

Action

Lead

Target Completion Date (month, year)

1.

Development and implementation of Staff Engagement and Communication Plan to support delivery of the Department's CSR changes

Director of Human Resources

June 2010 COMPLETED

2.

Delivery of regular CSR Briefing sessions with staff representatives to provide two way dialogue on the CSR changes

Director of Human Resources

Deputy Chief Executive

June 2010 COMPLETED

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3.

Develop a more open culture, through adoption of an Open Culture Action Plan, agreed by the Corporate Management Executive

Director of Human Resources

Chief Executive

July 2010 COMPLETED

4..

Establishment of a Staff Partnership Forum enabling a single body for consultation with all the unions and staff representatives recognised by the organisations

Director of Human Resources

July 2010 COMPLETED

5.

Development of a Whistle Blowing Protocol for the Department outlining how staff can raise concerns and escalate this if they feel their concern is not being appropriately addressed

Director of Human Resources

September 2010 COMPLETED

6.

Commence delivery of a programme of CSR Staff Workshops to help communicate the need for change but also involve staff in eliciting ideas for savings and delivering services differently

Director of Human Resources

Deputy Chief Executive

November 2010 COMPLETED

7.

Establish a comprehensive system for staff briefings to cascade business and service updates across the organisation, delivered by members of the senior management team

Director of Human Resources

Corporate Management Executive

March 2011

8.

Improve alignment of corporate support services with the needs of the Hospital, Community & Social Services and Public Health Department through understanding new customer requirements

Director of Human Resources

Director of Finance & Information

Chief Ministers Department

March 2011

10.

Building on previous work establish a Medical Engagement Plan to ensure clinical staff are effectively involved in and understand the business issues which affect delivery of services

Director of Human Resources, Managing Director Hospital, Managing Director Community & Social Services

May 2011

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