States Assembly | R-63-2011

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HEALTH & SOCIAL SERVICES REVIEW MAY 2011

Caring for each other, Caring for ourselves

Public consultation

Contents

IntrHealth and Social Seroduction from Deputvices Minisy Anne Pterryke, 2
About this consultation 3
Health and Social Care Services today 4
Future Challenges 6
Scenarios for the future 9 19
Financial Implications

Conclusion

Questionnaire

Introduction from Deputy Anne Pryke, Minister for Health and Social Services

There is perhaps no more important task than caring for our own health and wellbeing and that of our families and neighbours. As a former nurse, I acknowledge the commitment of front line health and social care workers to do the very best they can for their patients and clients balancing different pressures on their time, and making the best use of precious resources.

Health and social care services in Jersey are at a crossroads. Though people in Jersey receive good services today, this will not be the case in the future if we do not respond to the challenges ahead. Older people make an important contribution to our society. The number of people over 65 will double by 2040, and we need to find supportive ways of helping them make an even more important contribution, and take the opportunity to move towards a more independent way of living in old age. Decisions are needed now so we can continue to care for everyone in the years ahead.

These changes will affect everyone. If you re over 35 today, you will be over 65 in 2040 and will need to be able to access the services that older people take for granted today. Those of you who are currently under 35 will be responsible for paying the taxes to provide these services, so it is crucial that you have your say on how and where funds are spent.

We must act now. Existing capacity is due to be exceeded in some services in the near future. In addition, almost 60% of the senior medical workforce, as well as a significant number of nurses, are due to retire in the next 10 years, and must be replaced. New, but expensive, treatments are becoming available every year if the people of Jersey are to benefit from the latest technology in healthcare, we need to think about how we can fund it.

Over the last few months, the Health and Social Services Department (HSSD) have worked alongside colleagues from other Departments, with KPMG as advisers, to carry out a major review about what services Jersey needs now and in the future, and how we provide them.

We have been working with hundreds of health and community services staff, including hospital doctors, nurses and social care workers, GPs and colleagues from Family Nursing & Home Care to look for new ideas about how we provide services.

I would like to thank everyone who s taken part already, particularly those voluntary sector groups and charities who have also shared their valuable experience and ideas. Now we need your views.

This consultation document gives more information on the challenges we need to address, and asks a series of questions that will allow you to have your say on how we do this. We want to hear from all Jersey residents, so please take time to fill in and return the questionnaire at the end of this document.

Thank you, in anticipation,

Deputy Anne Pryke

Minister for Health and Social Services May 2011

About this consultation

Health and social care services in Jersey must be fit for the future to ensure they can provide for all Islanders in the years to come. There are many challenges ahead, and we must act now if we are to overcome them and provide safe, affordable and sustainable services in the years to come.

KPMG was commissioned by the Health and Social Services Department (HSSD) to review how services are provided today, what challenges are around the corner, and what steps will be required to ensure that we can continue to provide good quality care. KPMG have worked with a Ministerial Oversight Group and officers of the States of Jersey, and have spoken to many health and social care professionals working on the Island, as well as representatives from a range of Jersey s voluntary and third sector organisations, in order to hear their thoughts on the future of services. The findings of this review are now being shared in this public consultation, as we need to hear your views on the services used by you and your family.

Every Islander has a stake in these plans - as a patient, as a client, as a taxpayer, or as a friend or family member of someone who uses these services now or might need health or social care support in the future. Full details on how you can respond to the consultation, or contact us for further information, can be found at the end of this Green Paper.

Following the public consultation, the responses will be collected and independently analysed. A summary of the key findings will be published in the Autumn.

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Health and Social Care Services today

The first step of the review was to look at how services are currently provided here, and how this compares to the UK and other islands and territories of a similar size to Jersey.

Jersey and Guernsey have, over time, developed markedly different services. Indeed there are

many more similarities with the Isle of Man which, like Jersey, have tended to model their provision on UK NHS experience. However, it is clear from very recent proposals in Guernsey that all 3 island communities share similar challenges in delivering sustainable services and in recruiting health and social care staff.

In making the comparisons, there are several areas where Jersey performs better than others. For example, people tend to stay in hospital for a shorter time compared to other territories, allowing them to return home to complete their recovery. This is much more preferable to spending too long in hospital. Jersey has a high number of General Practitioners (GPs) in relation to the population, so it is easy and quick to get an appointment to see one. Our Social Care teams support children in stable residential and family placements, and our community based staff in mental health, older adults, children s and special needs services support as many people as possible with complex and often very challenging needs.

Jersey s benefits from a vibrant and committed third sector [1]. A range

of organisations provide information, significant services and support, to help people live active lives. Parishes also help to provide information and support to particular groups of patients, carers and their families.

Although there are a high number of GPs on the Island, there are relatively few nurses and social care staff working beside them in the community.

However, whilst health and social care today compare well to others today, that will not be the case in the years ahead if we continue to provide services in the same way. It would be both unsafe and expensive to try and stay as we are.

Many people are cared for in institutions when they could be cared

for better at home. Care staff do a great job caring for people in the community, but many older people are living in care homes. If care was available around the clock, many could still be living in their own homes. In addition, some children are currently cared for in residential homes rather than living with a foster family or being adopted. Caring for people in institutions is expensive, and may not provide people with the best care that they might reasonably expect.

Although though there are a high number of GPs on the Island, there are relatively few nurses and social care staff working beside them in the community. This means that often GPs are spending some of their time on procedures like measuring blood pressure, which in other countries is taken by a nurse. Similarly social care, counselling and carer support, if more available at local level, would take pressure off the GPs. It is expensive for the States of Jersey to have a large number of people being treated by unnecessarily highly skilled health professionals.

Hospital doctors these days are trained in an increasingly specialist way. Our hospital doctors are generally excellent but most of them were trained differently to enable them to care for a range of problems. This means that when our current hospital doctors retire it will be very difficult to replace them and nearly 60% of them will retire in the next 10 years.

Services are often not fully integrated between the different professionals who may be treating or supporting people, such as a hospital doctor, a GP and social care staff. For example, if a social care worker is to recommend the best care option for an individual, they need to be aware of the treatment the GP is providing if all the different professionals are not sharing information and working together, none of them will know what other care and treatment the person is receiving.

The challenges faced by Jersey are compounded by our Island status. Because Jersey has a small population (less than 100,000 residents), it costs more to provide some health and social care services than it would

for a larger population. Where there is a big population to use local services, the cost per person goes down. For example, a district General Hospital in England typically serves a population of 250-300,000 people to be affordable. With a population significantly less than this, it therefore costs more per person to provide treatment. An estimate of this Jersey premium suggests that it runs at an additional 20%, when Jersey s high cost of living is included. There is also no hospital down the road which can easily accommodate our patients at those times when beds are really under pressure.

Health and social care staff in Jersey do tremendous work treating and caring for everyone on the Island. And while Jersey s health and social care services compare well to other territories today, it is clear that some elements of the service will make it impossible for this advantage to be maintained. The next chapter considers some of the challenges we will face.

If we do not act now, some of the services we take for granted today will not be available in the future and we will be facing a major increase in costs.

Because Jersey has a small population it costs more to provide some health and social care services than it would for a larger population.

Future Challenges

In 30 years time, the make-up of the Island is likely to be different to the Jersey we know today. Many of these factors will have significant impacts on our health and social care service.

Increasing numbers of older people

Between 2010 and 2040 there will be a 95% increase in the number of people over 65, as shown in Figure 1. Older people use health and social care services more as they suffer with more health problems such as diabetes and respiratory and chest complaints than younger people. They also need more support to help them live independently in their own homes, such as help with washing and dressing. This will put the service under considerably more pressure in 2040 than today.

However, we should remember that older people make an important contribution to our society, and we need to find supportive ways of helping them make an even more important one. If properly managed the forthcoming population change could present opportunities, and the benefit of the greater wisdom and experience which comes with older age can be invested back into our civil society to enrich and sustain it.

Figure 1 Population change

2010 2040

= 1,000 people

Older people

Adults of working age Children

Children and older people are dependent on adults of working age. Because the number of people of working age will fall and the number of old people will increase, the tax paid will have to fund health and social care for almost double the number of dependents than it does today. In 2010, for each older person in Jersey, there were 3.9 people of working age paying taxes to provide health and social care services. By 2040, for each older person there will only be 1.8 people to support them.

Between 2010 and 2040 there will be a 95% increase in the number of people over 65.

Increased demand

If services are continued to be provided in the same way, The States of Jersey will have to spend 76% more on health and social care services in 2040 than it does today, as shown in Figure 2. We have to ask ourselves if we can afford this, and whether money alone can solve this problem.

Figure 2: Jersey spending on health and social care services if services remain as they are

The cost of health and social care is set to rise by 76% by 2040.

£32m Patient payment and other income

£36m total social security payments £430m £171m HSSD Net spend £296m

£239m

2010 2020 2040

Reaching capacity - hospital beds

The increase in the number of older residents and higher demand will mean Jersey will soon use up any spare capacity in the current system. This means that as more and more people require care, there will soon be no beds to treat them in, or community facilities to discharge them to. As shown in Figure 3 (below), by 2014 86% of bed capacity will be being used. Crucially this is over the 85% mark hospitals should always operate below this level to account for bed changes, cleaning and other operational factors. This level would be reached by 2014, and by 2040, Jersey would be operating at 135% capacity, clearly resulting in lengthy waits with not enough beds available.

If there is no increase to services in the community (including 24-hour care), the beds are likely to run out much more quickly. Patients (particularly older people) would be admitted to hospital as there wouldn t be enough services to

care for them at home. They would then stay in hospital for longer than necessary again, because there wouldn t be enough services to care for them at home. This will mean that people will have to wait much longer than they do today for treatment and care whether this if for an operation, or for a medical problem such as a chest infection. We would then need to significantly expand existing hospital facilities (build more beds and wards), which is very expensive.

Figure 3: Percentage of medical beds being used between 2010 and 2040

85%

2010 2014 2040

Percentage of beds filled in the busiest month.

Reaching capacity healthcare professionals

As well as running out of hospital beds, we will also face big challenges to ensure there are enough doctors, nurses, social care workers and therapists to provide the care that people need.

Many health and social care staff are approaching retirement age almost 60% of our hospital doctors will be eligible for retirement in the next decade.

Many of these retiring professionals are generalists , who can treat a range of conditions within a certain medical area. However, new health professionals across the UK are now trained to be specialists , focusing on more narrow, specific areas of care.

This means that every one retiring hospital doctor may well need to be replaced by more than one specialist doctor. This makes replacing the retiring doctors more expensive - while new doctors will bring new specialist skills, we may need two or three doctors to deal with the range of conditions that each of our current doctors treats. There are also significant problems in recruiting and retaining qualified nurses.

Jersey is a great place to live, but there are problems attracting and retaining health and social care staff. The high cost of living in Jersey and some rules for entry and residency mean it will not be easy to attract the next generation of health and social care staff to live and work on the Island.

Almost 60% of our hospital doctors will be eligible for retirement in the next decade.

Conclusion

The challenge ahead is clear. An ageing population will place significant additional demand on our health and social care services.

If we carry on delivering care in the current way, there will not be enough beds and facilities or staff to treat Jersey residents on the Island in the very near future.

As in all economies, funding is getting tighter. Doing nothing is not an option and we need your views on the decisions that need to be taken now, to ensure that the people of Jersey receive services that

are safe, sustainable and affordable in the future.

Scenarios for the Future

This chapter looks at three scenarios for the way in which care services can be provided in the future. These are:

Scenario One: Business as usual we keep the same structure for providing services as we have today, and increase spending so that services can be provided to meet growing demand.

Scenario Two: A small increase in funding we keep funding almost the same, and provide what services we can within this budget and accept that many services will be subject to means testing .

Scenario Three: A new model for health and social care we change the way services are provided. For every option, the review assessed whether it would be safe and affordable for Jersey.

We have also considered whether each option is sustainable in other words, whether it would be able to support excellent services for many years to come.

Scenario 1: Business As Usual

What will happen if we continue along the path we are on now, delivering services in the same way we do today? This means that despite the problems we identified earlier, we don t make any changes to the way our health and social services are provided, and we increase spending so that services can meet growing demand.

As previously mentioned, there are a limited number of care professionals in Jersey, and we cannot simply resolve this by attracting more people from overseas. As the population of older people rises, there will not be enough health and social care staff or beds in hospital and the community. The health and social care system will become over-stretched within the next couple of years. Although the system may be able to cope for a short while, it will not be able to cope in the longer terms, and health and social care services would be significantly disrupted in the coming years.

If there were unlimited money and care professionals we could continue to enjoy the health services we have today. But we would need to increase spending dramatically.

The health and social care system will become over-stretched within the next couple of years.

In 2010 the total cost of Jersey s health and social care is

£239m of which £171m is paid by the States Health and Social Services Department (HSSD). If we followed scenario 1 the total cost in 2040 would rise to £430m and HSSD s spending would rise to £320m (these figures of £430m and £320m are based

on today s price levels in practice, the actual amounts would be higher due to inflation).

This is unaffordable, and in addition the future challenges for staffing would not be addressed. This will mean there will be specific problems facing each area of care explained in detail on the next page.

More beds would be required in the General Hospital, along with more staff to treat

the extra demand - but it is increasingly difficult to recruit and retain nurses.

The impact on services

Self care iii. Non emergency hospital care

Many people take care of themselves when they are As demand increases for non-emergency care, such as suffering with a minor problem such as a cold, or when planned operations and procedures, there will soon be

they have a long term condition such as diabetes. no spare hospital beds. More beds would be required in

the General Hospital, along with more staff to treat the Many people live healthy lives, to help prevent getting ill in

extra demand - but it is increasingly difficult to recruit

the first place. This can be encouraged by health and social

and retain nurses.

care professionals (including GPs, nurses, social workers,

pharmacists and therapists) and the third sector providing In scenario 1, extra beds and staff are provided. This would information to people about how to stay healthy, and what require upgrading or rebuilding the hospital to ensure all services are appropriate for them. people continue to be treated as they are now, and this could

cost up to £300m. This upgrading would take time to do, and Information is currently provided by all these organisations

it is likely that the hospital would still run out of beds before and individuals. However, this information is often not

the necessary expansion was done, leading to long waiting coordinated, so different groups are producing the same

lists. This scenario also doesn t address the problems of how information as each other.

to replace the 60% of doctors who are due to retire in the

As scenario 1 maintains services as currently organised there next decade. As the system isn t changed, hospital doctors would be no room for improvement in self care support and GPs would still be treating people with minor problems, or information. Over time, this would reduce people s which will continue to be an inefficient use of their time. understanding of how best to care for themselves and each

other, meaning people would seek medical advice at A&E or iv. Emergency Care

from a GP when it was not required. This further increases Keeping the same system will not address the current

the pressure on health professionals. problem of too many people arriving at A&E who could be

treated safely and effectively elsewhere. Though people

Primary Care would still be seen quickly upon arriving at A&E in the short Primary care is the first port of call for many people who term, if people continue to attend A&E despite only needing

need to see a health professional. In Jersey, most primary minor treatment, soon this will mean that waiting times at care is undertaken by a GP. A&E will start to increase. In addition, there soon won t be By keeping the service as it is today people will still find it enough beds, and expanding the hospital would take time easy to get an appointment to see their GP. However, under and be very expensive.

the current system, some people choose to go to A&E first,

even if their condition is not an emergency so A&E would

still have too many people attending who did not require

urgent care.

The shortage of nurses in primary care would also not be resolved. This would mean GPs would continue to deliver basic care such as ear syringing, rather than concentrating on more complicated and serious conditions. And as the demand for primary care is predicted to increase we would need to employ many more GPs, rather than employing a range of staff who could provide care.

Services for Older People

As the number of older people will increase the most,

it would be very expensive to continue providing care

as we do now. Without significant extra funding, many services which older people rely on today would no longer be available at anywhere near the level required. Without any changes to the current system, there would still be

a shortage of community nurses, social care staff and appropriate equipment and accommodation to maintain independence. This would mean many older people would still be cared for in residential care homes when they could best be cared for at home. Not only is this more expensive, but it is also not the best way to receive care most older people would rather be treated at home if at all possible.

In addition, nursing and residential care homes will soon have no space left for the growing number of older people

this could happen in the next two years. Building new care homes would take time and a large amount of extra funding. If patients can t be discharged from the hospital into community based facilities, then new patients requiring treatment can t be admitted and waiting lists and waiting times would quickly increase. This would also mean that we run out of hospital beds earlier than 2017.

Younger Adults Social Care and Mental Health

As the adult population will remain about the same,

it would be possible to continue providing the same services as today. However, there would still be the serious problem of replacing staff due to retire in the next decade.

Children

The child population is due to stay broadly the same in the next 30 years. If the child population does slightly increase, there would have to be a relatively small increase in spending to provide the extra services required. However, the risk is that scenario 1 makes no attempt

to improve the way children s care services are provided. This means that some children may continue to be housed in a children s home, which compared to living with a foster family is more expensive and is often a less attractive option for the child. Others would be denied access to a full range of child and mental health services or fail to be offered a range of preventative measures that could be put in place to improve the quality of their lives and increase their potential as they mature.

Conclusion

For each area of care, scenario 1 has a high level of risk. Ultimately, Jersey would not be able to afford all the additional costs of care, including the extra staff and beds and facilities. Keeping the system as it is today is simply not sustainable. To address the problems that we will begin to face in the next 1-2 years, we need to act now. Scenario 1 demonstrates that by keeping the system as it is today, we will be ignoring the problems we are facing, and missing an opportunity to make the crucial changes that are required.

Scenario 2: A Small Increase In Funding

If we only increased the level of funding in line with inflation (a gradual increase in line with the cost of living) there would be a significant disruption to services, risking patient safety. There would not be enough money to cope with an increasingly elderly population demanding more health and social care services, and there would soon not be enough services to care for everyone. This would mean some services would need to cease, and those services that were still provided would not be available to everyone.

Some difficult decisions would have to be taken within the next 18 months. For example, how do we decide who gets treated first? What happens to those people who need care but can t be seen quickly enough? If the States of Jersey is not providing extra money for health and social care services, where will the funding come from? Will some people not be able to obtain the care they need at all? How will the significant challenges in recruiting and retaining health and social care professionals be met?

As there would be no money to respond to growing demand, waiting lists would rise immediately, as there would not be enough health professionals or beds to treat everyone who required care. In the short term a system of rationing would have to be introduced. Either people would need to be more unwell before they received treatment, or only those earning below a certain amount would be provided with free care. However, even this would be difficult to provide in the long term, and some services would have to cease.

If we followed scenario 2 the total costs of Jersey s health and social care would rise rapidly; just as they would do in scenario 1. The total cost would rise from £239m in 2010 to £430m in 2040 but the States spending on health and social services would rise much more slowly, with the HSSD budget rising from £171m in 2010 to £178m in 2040. This increase is not enough to deal with the significant growing demand for health and social care services. As a result, many services will no longer be available, and people might ultimately have to pay for all their own care (apart from emergency care) through private insurance.

Scenario 2 leads to difficult decisions

The most obvious problem is that scenario 2 does not provide enough money to continue providing care as it is today.

Because there is no extra money being spent, scenario 2 does not provide the increase in staff numbers and beds that

is required to care for the growing population. This will lead to a rapid increase in waiting lists for hospital care, and longer waiting times for people in A&E. Beds in older care homes would quickly fill up, and people would have to live in their own homes for longer without home care support. This may mean a relative has to give up work to look after them, or they would struggle to cope alone. Health and social care professionals will be under a great deal of pressure as the number

of people waiting for care builds up.

For many older people, their health will deteriorate the longer they wait therefore once they do get the treatment they need, they are likely to require a longer stay in hospital. If people are staying in hospital longer, waiting lists will continue to grow.

Within the current system, Jersey provides good health and social care services. There are very few areas where service provision is inefficient, therefore increasing efficiency won t free up enough spare resources (such as hospital beds or staff time) to resolve the problems that scenario 2 brings.

These problems mean that very difficult decisions would need to be taken in the very near future. These could include the following:

Restrict care in Jersey

There would not be enough money to provide all the care the people of Jersey need, so some services would simply have to stop being provided. Some people would have to pay privately or be transferred to the UK which could cost even more and would increase the time they had to wait for care, leading to further disruption for people and their families. Some treatments would not be available at all in Jersey.

Reduce the number of people who are eligible to receive care

It would not be possible to provide all the services that

are provided today. This means that decisions would

need to be made about who is allowed to receive the significantly reduced free health and social care services still provided there simply won t be enough for

everyone. In scenario 2, the threshold that gives access to free health and social care would be raised meaning that many individuals and families on lower incomes would not be able to have free healthcare as they do today.

Individuals would also need to pay for more of their social care, including any equipment they need in their homes to enable them to continue living there.

Raise the criteria for treatment care and support

It would not be possible to treat or offer care to everyone as quickly as they are today, nor would it be possible to provide the same support at home that people receive today. To manage this, people would have to wait until they were more unwell than they are today in order to receive treatment. This would mean people would have to wait longer to be seen by a doctor or to have an operation only those who were very ill would be eligible for care.

It may also mean that people will struggle to cope at

home without any support for much longer even if they are really unable to care for themselves fully. For example, they may only receive help with washing once a day instead of twice. As discussed earlier in this paper, some of the problems facing Jersey will happen sooner rather than later. This means that some of the steps above would need to be taken next year if scenario 2 was chosen.

Ultimately, restricting care would lead to very limited services being provided with perhaps only emergency services being available in Jersey.

Because there is no extra money being spent there will be a rapid increase in waiting lists for hospital care and longer waiting times

in A&E.

Impact on services

Scenario 2 would also have severe implications for all services in Jersey.

By keeping funding the same as today, it would be impossible to provide the same quantity and quality of care for older people.

Self Care

The growing pressure on health and social care professionals would mean staff would have less time to care for people at home or in the community. There would be a risk that more people would be kept in hospital, even if home care is more affordable and preferable for the patient. There would be no additional funding to ensure health information was properly targeted. This would mean many people would still find it difficult to find the information that would help them care for themselves. Health information would be uncoordinated, and with

no funding available, it wouldn t be possible to update the information as regularly as required.

Primary Care

By keeping States funding the same despite a growing population, people would have to pay a higher charge to see their GP. Nurses and pharmacists are able to support GPs by providing primary care. However, this scenario does not allow any funding to employ the extra nurses required, and pharmacists maybe unwilling to provide more services if there is no money to pay for them.

Non-emergency care

Non-emergency care services would soon be under significant pressure, as there would be no funding to increase the amount of care required by a growing and ageing population. There would be no money to maintain or improve the General Hospital and other nursing, residential and social care facilities also in need of investment or replacement and it would still be difficult to recruit and keep staff. Work pressures on staff would increase to unsafe levels.

Emergency care

A&E would be unable to deal with all the people arriving at the General Hospital. There would be no extra money to provide more hospital beds and more staff, so people would have to wait longer at A&E. Some people would be sent away to their GP (where they would have to pay) if their condition is not regarded as serious enough. Even then, there is a risk that not all emergency cases could be seen in Jersey. This might mean that some people arriving at the General Hospital only receive enough care to make them stable, with the rest of their treatment being provided in the UK.

Older people

There are large risks for services for older people in scenario 2. By keeping funding the same as today, it would be impossible to provide the same quantity and quality of care within a year. This would apply to hospitals, residential and nursing care, and care provided in people s homes. It would result in older people seeing their community nurse, social worker or paid carer less than they do today, due the larger number of people each professional will be caring for. Ultimately, older people will not be able to access all the services they can today there simply won t be enough money to provide care for all and they may become more acutely ill and end up in hospital in any case. Alternatively, more people will have to pay for care privately.

Younger Adults Social Care and Mental Health

As the number of young adults is expected to remain relatively constant, it would be possible to provide the same services as today for the same funding. However, there would still be the same risk as in scenario 1 it will be difficult to replace all the staff expected to retire in the next 10 years.

Children

Scenario 2 allows for minimal resources to be available for children s services such as services like professional fostering, and early intervention to support children from deprived backgrounds. However, children s services in Jersey are now inspected and monitored from the UK, and it is clear that significant improvement in residential homes is expected there would be a risk that not all the necessary improvements could be made if only limited extra funding available.

Conclusion

By only increasing spending by the level of inflation, there would simply not be enough funds to continue providing services that Jersey enjoys today every area of health and social care would be affected, with many services no longer being provided, or no longer available for everyone. Difficult decisions would have to be made within 18 months.

Scenario 3: A New Model For Health and Social Care in Jersey

What changes need to be made to the way in which health and social services are provided, and how would they improve patient care? Option 3 looks at what a new model for health and social care might be.

Scenario 3 is both safe and sustainable, providing the care needed long into the future. The funding required is still substantial, but significantly less than required for Scenario 1, and services would better reflect the need of Jersey s population.

People would see the right healthcare professional at the right time in the right place. This prevents the problems seen in scenario 1, where services provided soon become unaffordable and scenario 2 where many will have been discontinued. Social care needs would be met within people s own homes wherever possible.

In scenario 3 the costs of health and social care would rise but, by redesigning services in this way, the increase would be slower than in scenario 1. In scenario 3 the total costs of health and social care would rise from £239m in 2010 to £393m in 2040. Spending by HSSD would rise from £171m to £290m (not including inflation). This is less than the funding of £320m required for scenario 1. Crucially, scenario 3 reforms services so they can continue to be provided long into the future.

Scenario 3 people get the right care at the right time by the right staff

Neither scenario 1 nor scenario 2 respond directly to the challenges Jersey faces though you have your chance to let us know what you think by responding to this consultation.

The review concluded that the only option for Jersey is to consider a new way of providing services. This new model would be built on the following series of principles these are outlined below, before the chapter looks at what this might look like in practice.

People receive the right care in the right place

By ensuring that professionals are in

Hospital Doctor communication with each other, people

GP will benefit from more integrated care.

Figure 4: Teams of different health and social care professionals work together to provide care based around the patient.

Patient

Nurse

Pharmacist

Social Care Worker

i. People receive the right care in the right place With a growing population, Jersey must ensure all

Many people are treated or supported by several resources provide value for money, as the Island cannot different healthcare professionals for the same condition afford to have resources, such as the General Hospital,

such as hospital doctors, GPs, nurses, social care workers being used inefficiently. This can be brought about by the and therapists. To make sure the best care is provided, principles above, making sure that expensive services are each professional must be aware of what care the other all used as effectively as possible.

professionals are providing. This can mean professionals ii. People receive care at the right time

are sometimes duplicating care being provided by others,

or worse, an aspect of care is not provided by anyone as Demand for health and social care services will rise due each professional thinks someone else is providing it. By to the increases in the older population. To make sure ensuring that professionals are in communication with services can be provided for all those that require them, each other, people will benefit from more integrated care. individuals will need to understand when they should

This will also mean people don t have to describe their seek medical help. Specifically, when a condition is serious medical history each time they see a different professional enough that they should go to A&E, or whether they can

that information will already have been passed on. safely wait until their GP can see them the following day. Similarly, people need to know when they should seek

medical advice for minor complaints, as they can often

Support to help people care for themselves safely and more effectively, ensuring

the GP s time is not taken up unnecessarily.

live independently in

their own home will Mown homes. Theany people will need help ty may need help underso live independently in their tanding what be essential as it could supporsupport thet for people at home is esy can receive, and who wsential, as it could provide itan avoid or . But avoid or delay the delay the need for long term nursing home care.

need for nursing and iii. People receive care from the right staff home care. Ppreople should be trofessional. This is ceatoved by the mosered in part in the points abovt appropriate care e.

In the future, alternative professionals for treatment

Jersey has to expand the amount of care it provides. should be considered. This is because in scenario 3,

To do this, different health and social care professionals care professionals will have bigger roles, providing more would work together closely in teams (these are referred services than they do now. Rather than a GP helping

to as multi-disciplinary teams , and will include hospital a patient manage their diabetes, this can be done by a doctors, GPs, nurses and social care workers). For nurse working at the GP s surgery. Instead of a seeking an example, some GPs would be based at A&E, so they can appointment to see a nurse to get their blood pressure

see people with minor conditions straight away, freeing measured, a patient can walk into a pharmacist to receive up the hospital doctor to do the more complex care they this simple procedure. And rather than older people

are trained for. Third sector organisations will be involved needing admission to a residential home, they can be more. Not only will they continue to provide health and supported to live safely within their own home for longer. social care services for people, they will also help people Carers will be offered support to help them maintain the understand where they need to go for care, and if they care they give so readily for their loved ones. As health could be treated more effectively through self care. More, and social care professionals start to expand the care they and different, healthcare could be available for example, provide, it will be crucial that people know which care monitoring systems installed, with their agreement, in professional to see for which care. This will keep health people s homes so as to provide links to services that can and social care services running as efficiently as possible.

provide support and assistance as and when required. This

will mean services are being used more efficiently, making

more services available to those that really need them.

Care will be based around the individual. When health or social care is needed, the multi-disciplinary team will set out what care the person requires from, for example, their hospital doctor, their community nurse and their social worker. This joined up way of working means care will be based around the individual, not around

the different healthcare professionals that may

treat or support them.

Impact on services

There would be new ways of providing services in each area of care.

1. Living Healthy Lives

People given information and education on staying healthy and active.

5. Independent & 2. Help at Home Voluntary Groups People have equipment

Charities, community & Self Care to help care for themselves leisure centres all provide and stay in their home.

care and information.

4. Community 3. Community Help Based Professionals People given training

Professionals visit to help them care for people in their homes themselves in their

if care is needed. own home.

Self Care

Increasing self care would have a significant impact on the use of services, with fewer GP consultations, a reduction in visits to A&E, and fewer admissions to mental health facilities or long term care homes. This would all help towards the overall target of using facilities more efficiently.

Jersey already has an excellent foundation of self care support upon which to build. Alongside the services provided by HSSD and the Education, Sport and Culture, many charities such as The Bridge, Les Amis, Brighter Futures, Brook, Mencap, the Jersey Alzheimer s Association and Silkworth Lodge provide indispensable help for people of all ages to care for themselves and family members. Similar initiatives are required to bring support and advice for older people and those that are living with long-term conditions such as diabetes, chest or respiratory conditions and depression.

However, despite this excellent work, there is a need

for a more coordinated approach to provide information for people. This would be supported by setting up a forum of organisations and individuals, including doctors, nurses, social care staff, therapists and third sector bodies and patient representatives, to develop a coordinated approach to providing self care support.

To support people in caring for themselves at home, more equipment would be provided, such as mobility aids to help disabled people stay independent and living in their own homes. More nursing and social care support will be provided in the community, so people don t have to go into residential care unnecessarily.

By taking care of ourselves and our family, with the help of good professional support if and when we need it, we can stay in good health and relieve the pressure on our hard-working doctors, nurses, social care workers and hospitals as demand on services grows.

Primary Care

GPs are the main providers of primary care services

in Jersey, but in the UK and other European countries, qualified practice nurses and other staff perform a range of functions, including minor operations, monitoring people s blood pressure, and running clinics for conditions such as asthma, diabetes and skin complaints. Similarly local pharmacists can play a greater role in prescribing and the provision of additional services such advice and support to stop smoking and reduce weight.

Non Emergency Care

To support the increasing demand for non emergency care, some GPs would be based at the General Hospital

to provide support for hospital doctors. Some GPs

would have some extra spare time, as they would be sharing their work load with nurses, as explained above. These GPs are now able to spend some time each week providing care for people in hospital. For example, one GP is already performing endoscopy at the hospital (this is a simple procedure where a doctor looks inside the patient using a small camera on the end of tube).

GPs would also be able to do minor operations as happens in other jurisdictions, to take some of the pressure off hospital doctors. Hospital doctors would spend a certain number of days a year visiting the UK for training purposes, to ensure they are kept up to date with new treatments and procedures.

In addition, where practical, UK hospital doctors would come to Jersey to undertake some specialist operations, rather than sending some people to the UK, and provide consultations using video conferencing with the patient

in Jersey and the hospital doctor in the UK. Your ongoing care would also be planned from the moment you are admitted to hospital, to ensure your stay is as short

as possible. This provides much less disruption for the patient and their family.

Emergency Care

People would be seen in the right place, by the right care professional and at the right time.

To make sure, people who suffer an accident will call a Health and Social Services emergency line. They would speak to a health professional who will advise them what to do next. The process is shown in figure 6.

By arranging services in this way, only those people who really need emergency care would be treated in A&E by the right professional. By making other options clear and easy to use, it is possible to make sure that everyone gets the assistance they need when they need it.

Older people

By putting a strong medical and social care team in the community older people would be able to maintain their independence and stay in their own homes for as long as possible.

More staff would be working in the community

with more GPs, nurses, social workers, therapists and specialists available to visit people in their own homes, 24 hours a day. These community based professionals would have regular contact with each other to ensure they know what other care the person is receiving this would make sure all care can be planned to fit around the person s specific needs. This can help reduce the pressure on those people caring for relatives at home, as they receive more support too.

Equipment for daily living and adaptations to housing will need to be extended to ensure that independence of service users is maintained.

A greater range of services would be available, including respite care so the carer gets a break and a rest, day

care and a range of equipment to support people in daily activities such as cooking, washing and doing their laundry. Expert patients would also support one another. These

are people with the same conditions who offer advice and guidance based upon their own experiences, to help others cope with their illness and care needs.

Older people in this situation almost always would rather stay in their own home. In addition, people being cared for at home means less are admitted into expensive residential care before they need to be. This consultation has already shown how residential care space would be severely limited in the future, so keeping people at home where possible would help take the pressure

off care homes leaving beds available for those

people whose needs are too complex to be cared

for in their own homes.

Accessing the right care at the right time

Figure 6: Managing people at A&E more effectively

You should make an appointment to see your doctor in the next couple of days.

Take two You need to paracetamol come to A&E

and get some rest. straight away.

The focus for improving services to children would be earlier intervention, to prevent health or social problems getting worse and to reduce the number of children in residential care homes.

Younger Adults Social Care and Mental Health

Similarly with older people, care for adults requiring social care and mental health services has tended to involve people being treated in residential care. A new model of care for this group would mean more care provided in the community.

There would be greater provision of talking therapies, which has been shown to work more effectively for conditions such as depression than simply giving the patient medicines. This may cost more in the short run, but as it has a greater chance of success, would prevent more health and social care services being required in the future.

Community hubs could be set up these would be drop in centres where adults can go to see health professionals, social care staff, or representatives from third sector groups. These hubs would improve access, helping to identify possible problems quickly and provide care before the problems gets worse.

Services for Children

The focus for improving services to children would be earlier intervention, to prevent health or social problems getting worse and to reduce the number of children in residential care homes, moving children in with foster families where possible.

Newly established early intervention workers would assess vulnerable children s needs, and ensure those needs are matched with services. The early intervention worker would also make sure that the many different agencies (the Education department and the many health and social care professionals) worked together

by having one person responsible for coordinating care, that person can check that no elements of care are falling between the gaps.

Comparing children in Jersey who don t live with their family with similar children in the UK, 20% more in Jersey live in children s homes rather than with foster families. Providing more funding to support more foster homes would be a priority raising the status and profile of

foster caring would hopefully increase the number of applications to be a foster carer.

When mental health problems aren t detected early in children, this can often lead to behavioural problems,

and possibly even a descent into crime for some young individuals. This is a missed opportunity which can blight people s lives and have a lasting and long-term impact upon them and their families.

In Jersey, a number of organisations are working hard to address the needs of families. But States bodies and voluntary sector partners are not working together as closely as they could be which can lead to confusion, duplication, or gaps in provision. This would be addressed urgently in scenario 3.

Conclusion

We need to act quickly in order to meet the challenges of the coming years. As outlined throughout this scenario, every group of services will need to change if we are to care for everyone in Jersey. The successful future of health and social care services relies on improved team working across traditional professional groupings and through strengthened links between those services provided by Health & Social Services and partners in the third sector. This can only be achieved by making sure people see the right health professional at the right time in the right place.

Financial Implications

Providing health and social care will inevitably cost more money over the next 20 years. We will need more doctors, nurses and other care staff for a growing number of older people, we will need to pay for more drugs and treatments and we will need bigger and different health and social care facilities. We want to be clear about the potential costs of these changes and what these might mean for us in Jersey.

How costs might rise

In 2010, as a community, we spent £239m on health and social care. £171m of this was spent directly by the States Health and Social Services Department, £36m by the States Social Security Department and £32m by other groups and individuals including the payments we all make for GP consultations.

Figure 7: Summary of Total Expenditure under all three scenarios

HSSD Net Social Security States Total Other Total Public & Expenditure Private

2010 2040 2010 2040 2010 2040 2010 2040 2010 2040 Scenario 1 171 320 36 54 207 374 32 56 239 430 Scenario 2 171 177 36 38 207 215 32 215 239 430 Scenario 3 171 290 36 54 207 344 32 49 239 393

Note: Other = All non States expenditure including all contributions form other parties, user pays, third sector and private insurance schemes.

Providing health and social care will inevitably cost more money over the next 20 years.

Scenario 1 would mean our services would remain much as they are now, but costs would rise very rapidly. Rather than the £239m we currently spend, we estimate in 2020 we would need to spend £296m and this could increase to £430m a year by 2040 an increase of 80% over 30 years. All of these figures are at 2010 prices so inflation would be on top of this as well.

If we adopted Scenario 2, we would be restricting or reducing services to minimise costs. This would involve rationing many services, something Islanders are not used to in the Jersey Health Service. The budget for the States Health and Social Services Department would increase from £171m to £177m but would increase only in line with inflation after that. With these financial restrictions, while demand for care rose rapidly people would soon have to pay directly for their own health and social care or might not receive it at all if they could not afford to pay.

Scenario 3 would mean costs would rise but by much less than under scenario 1. From £239m in 2010, costs would rise to £292m in 2020 and £393m in 2040 an increase over 30 years of 64%. And as well as the services being cheaper than under scenario 1 they would be better too. More care would be provided in people s own homes and in other places local to them which would be much more convenient.

We will be actively managing our services to deliver the best value for the resources available. Scenario 3 describes changes we can make such as introducing more support for people in their own homes, providing support from an appropriate mix of nurses, doctors and other social care and health staff working in the community.

We will need to undertake major works to refurbish, or even fully replace, the General Hospital and the other facilities from which we deliver care in the community.

Whatever approach we adopt we will need to undertake major works to refurbish, or even fully replace, the General Hospital and the other facilities from which we deliver care in the community. Whilst the hospital has served us well, some parts of it are now in urgent need of improvement and updating.

It certainly won t last thirty years. Hospitals in particular are very complex and expensive to build. If we were to build a new hospital now it would probably cost us between £250m and £300m and we are also working on the costs for extension

and refurbishment of both the hospital and other facilities.

How the costs might be funded

These funding pressures are faced by countries around the world and there are different models of health care funding. There are three main sources of funding that Governments use for health and social care. These are:

Insurance A social insurance scheme, whereby people pay into a fund that specifically raises money for health and social services. This is already planned for long term care from 2013. [This is common in Europe.]

Taxes By increasing general taxation or sales taxes, we could create extra revenue for health and social services. [This was the recommendation of the Wanless report in the UK.]

Direct contributions from people People already pay when they visit their GP. In order to generate

more funding, this amount could be raised. Furthermore, charges could be extended beyond primary care. [Elements of this exist in Guernsey].

Given the very substantial increases in the number of older Jersey people, and the inevitable demand for health and social care we can expect the total cost of our health and social care to increase. We will be doing everything possible

to improve efficiency so that each case costs less but the total cost will rise. We therefore need to find

the best possible way of paying for the increased levels of care that we as Islanders will need. Jersey, with strong public finances, is in a better position than most countries to deal with this.

Conclusion

As Jersey s population grows older, our health and social care needs will grow. This puts our doctors, nurses and therapists, our social care facilities and our General Hospital under added strain. If we don t make changes to our system, the needs of our Island will very soon be greater than our system can bear.

Our Island s size and location bring bigger challenges in the future. We must decide how to meet these challenges, to ensure we have a system that is safe, sustainable and affordable.

We want a system where:

• Everyone can access the right care they need when they need it

• Care is provided by the most appropriate professional

• Care is provided in the right place for the individual in hospital, in the community or at the person s home.

• Islanders take on more responsibility for maintaining their own good health. They are well supported by doctors, nurses other care workers to improve their health and a social wellbeing.

• Services are organised around the individual. Teams of health and social care workers together with the third sector, work better together to meet individual needs.

• Services reach the most vulnerable people in society of every age, as early as we can.

If we have a health and social care system that delivers this, the health and treatment of Islanders will improve and our public resources will be spent more efficiently.

The conclusions of the review are that both Scenarios 1 and 2 have severe limitations. Scenario 1 would require significant extra funding and would still see many services badly affected, whilst Scenario 2 simply does not provide enough funding to allow Jersey to provide the majority of services currently available to people.

The review has therefore concluded that a new model of care is required for Jersey, which is set out in Scenario 3. Safe and sustainable services will cost more, but less than would be the case with option 1. However, the purpose of this consultation is to allow the people of Jersey to contribute their thoughts on all three scenarios.

Our conclusion is that only by making changes can we tackle the significant challenges that lie ahead. Doing nothing is not an option. Now we need the views of Islanders to help turn this vision into a reality.

Please let us know your views

• Do you agree with the review s conclusions on Scenarios 1 and 2?

• Do we need a new way of providing services?

• Are there any parts of Scenario 3 that should be adapted?

• Are these additional changes that should be made?

There are lots of ways to do this.

Respond to the questionnaire that is provided with this Green Paper and return it to:
The Public Consultation Office, FREEPOST JE 706, Jersey JE1 1AF

Complete the questionnaire online at www.gov.je/consult.

Pick up a harthe Parade entrd cancopy e of the Generfrom all Parish Hall s, Mal Hospital. Yorier House, the Jerseou can also request a paper cy Library and opy of the consultation by emailing: l.journeaux@health.gov.je or by calling 440421.
Aof the Ministtend public meetingsters, charities and he to hear moralth and social ce about the plans and ask quesare professionals who artions e leading this work. These will be held at a number of venues including

The RJAHS at Trinity , Les Quennevais School and St Pauls centre in St Helier.

RJAHS, Wednesday 22 June, 7.30pm 9pm

Les Quennevais School, Wednesday 13 July, 7.30pm 9pm St Paul s Centre, Tuesday 02 August, 12.45pm 1.30pm

Or drop in to The Ambulance Service Roadshow:

St Clement s Parish Hall , Tuesday 21 June, 11am 3pm St Lawrence Parish Hall , Tuesday 09 August, 11am 3pm

Visit the Son the consulttates of Jeration and rsey weview prebsit oce t eso sign up ts on wwwo r.goveceiv.je/e prconsultogress updates
Fpublic placind out mores such as supermarke by visiting information displayets and the Jerses in ky Librey meearyting points and .
Find out new developments and information through the local media.

Additionally, our team will be sharing these plans with groups of service users by visiting them in their clinics and residential homes. If you represent a group or organisation and would like more information please get in touch.

A shortened At a glance version of this document is available from all Parish Hall s, the Jersey Library and will also be available at the public meetings.

Next steps

We will read every reply that we receive and your views will inform the next stage of this work. We will publish an analysis of all the replies we receive later in the year, and also publish our updated plans for health and social services.

Your view matters. Thank you for taking part.

Questionnaire

Thank you for taking the time to respond to this consultation. This Green Paper is about the big challenges that the Island faces; we are therefore consulting on the broad options available. This is not a consultation on detailed proposals. We acknowledge that all three options outlined will require further debate on detailed proposals in the future if the States decide to proceed with them.

This consultation does not take place in a vacuum. The research undertaken for this Green Paper suggests that the third option is the most viable one. However the States of Jersey needs to hear what islanders, representatives from other organisations, charities and voluntary groups as well as health and social care professionals think. This is why we are undertaking this consultation.

Whilst the existing evidence points in one direction we want to check that this is the direction that the people

of Jersey want to go in. The final decisions will be made by the elected politicians of the Sates of Jersey balancing up the facts, and the views expressed by the public through this consultation. Care will be taken to ensure that

we listen to the voices that are not normally heard on the island. The option that receives the most vocal

support will not necessarily be the one selected.

Looking ahead in to the future, how important will it be for you personally that you can have a wide range of health and social care services delivered here on the island?

Very important Fairly important Not very important Not important at all Don t know

Looking ahead in to the future, how important will it be for you that health and social care services are free or affordable and available to all?

Very important Fairly important Not very important Not important at all Don t know

The cost of providing health and social care services will increase in the future, not least due to the ageing population. How much do you agree or disagree with the three scenarios presented in the Green Paper?

Scenario One: Business as usual we should keep the same structure for providing services as we have today, and significantly increase spending so that services can be provided to meet growing demand.

Strongly agree Slightly agree Slightly disagree Strongly disagree Don t know

Scenario Two: A small increase in funding we should keep funding almost the same, provide what services we can within this budget and accept that many services will be subject to restriction or may no longer be available free.

Strongly agree Slightly agree Slightly disagree Strongly disagree Don t know

Scenario Three: A new model for health and social care we should change the way services are provided, so patients see the right health or social care professional at the right time in the right place. Changes will affect the way that health and social care works on the island, there will be some cost increases (but less than in Scenario 1).

Strongly agree Slightly agree Slightly disagree Strongly disagree Don t know

Please add any comments you have on these three options. Why did you rate them in the way you did? Are any options unacceptable to you? Are there challenges with any of these options we might not have considered?

Please score the following statements based on how much you personally agree with them.

In the future, people in Jersey should have a responsibility to care for themselves provided they have been informed how to.