Health and Social Services: A Sustainable Primary Care Strategy for Jersey 2015 – 2020

SUSTAINABLE PRIMARY CARE

STRATEGY 2015-2020

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CONTENTS

1. MINISTERIAL FOREWORD ........................................................................................................................ 3
2. EXECUTIVE SUMMARY............................................................................................................................. 4

1. WHAT IS PRIMARY CARE.............................................................................................................................. 4
2. THE CASE FOR CHANGE ................................................................................................................................ 4
3. THE STRATEGY ........................................................................................................................................... 5
4. IMPLEMENTATION PLAN ............................................................................................................................ 10

3. INTRODUCTION AND BACKGROUND ..................................................................................................... 11

1. WHAT IS PRIMARY CARE? .......................................................................................................................... 11
2. MEASURES OF HEALTH SYSTEM PERFORMANCE .............................................................................................. 13
3. THE WHITE PAPER: A NEW WAY FORWARD FOR HEALTH AND SOCIAL CARE (P82) (2013 – 2021). ...................... 15

4. STRUCTURE OF THE CURRENT PROVISION OF PRIMARY CARE SERVICES IN JERSEY ............................... 19

1. PROFILE OF PRIMARY CARE PROVIDERS IN JERSEY ........................................................................................... 19
2. WHAT WORKS WELL IN JERSEY AND WHAT HAS BEEN ACHIEVED? ..................................................................... 25

5. WHY DO WE NEED TO CHANGE? ........................................................................................................... 28

1. FUNDING OPTIONS FOR HEALTH ................................................................................................................. 28
2. STRATEGIC PLANNING AND POPULATION POLICY ............................................................................................ 30
3. INCREASE IN NUMBER AND COMPLEXITY OF PEOPLE WITH LONG TERM CONDITIONS ............................................. 31
4. ACUTE HOSPITAL CARE IN JERSEY ................................................................................................................ 33
5. PERVERSE AND MISALIGNED INCENTIVES....................................................................................................... 34
6. INFORMATION (IT) AND DATA ACROSS PRIMARY CARE.................................................................................... 36
7. CLINICAL SUSTAINABILITY OF PRIMARY CARE ................................................................................................. 37
8. INTEGRATION .......................................................................................................................................... 38
9. THE CASE FOR CHANGE: CONCLUSION.......................................................................................................... 38
10. WHAT ARE THE IMPLICATIONS OF DOING NOTHING? ....................................................................................... 39

6. DETAIL OF THE STRATEGY ...................................................................................................................... 40

1. THE 5 AMBITIONS OF THE SUSTAINABLE PRIMARY CARE STRATEGY IN JERSEY....................................................... 40
2. AMBITION 1 – PATIENTS ........................................................................................................................... 41
3. AMBITION 2 – PAYMENT ........................................................................................................................... 54
4. AMBITION 3 – PARTNERSHIPS (INTEGRATION) ............................................................................................... 63
5. AMBITION 4 – PEOPLE .............................................................................................................................. 74
6. AMBITION 5 – PROCESSES ......................................................................................................................... 78

7. IMPLEMENTATION PLAN ....................................................................................................................... 83

1. STRATEGY APPROVAL PROCESS ................................................................................................................... 83
2. TARGETTED COMMUNICATION.................................................................................................................... 83
3. NEXT STEPS ............................................................................................................................................ 84

1  Ministerial Foreword

Primary Care must remain central to our health and social care system; it looks after us from cradle to  grave  providing  General  Practice,  Dentistry,  Optometry,  Pharmacy  and  Community  Nursing services in our local communities; the services that are critical in keeping us well and supporting us at home.

Primary care services in Jersey have been developed locally over many years and are different from other  jurisdictions  but,  like  other  jurisdictions,  high  quality  safe  and  effective  Primary  Care  is essential to promote health and well-being and to protect our very young, vulnerable and elderly populations.

The White Paper Caring for each other, caring for ourselves' (2012)[1] and the subsequent Proposition to the States, A New Way Forward for Health and Social Care' (P82/2012) [2], outlined a vision for health and social care which is safe, sustainable and affordable, with integrated services delivered in partnership. As a result of P82, more services are now provided in local community settings for example midwifery, re-ablement and sustained home visiting. But we could do even more, so that the right care is provided, in the right place, by the right person, at the right time – and at the right cost. This strategy sets out our vision for achieving this aim.

I know that there has already been a considerable amount of work undertaken in producing this strategy. I would like to thank everyone involved in contributing to its contents and look forward to their  support  in  the  future  as  we  begin  the  journey  of  implementation.  With  your  help  I  am confident we can make a positive difference to people's lives.

Senator Andrew Green MBE Health and Social Care Minister States of Jersey

2  Executive Summary

This strategy outlines the direction of travel for developing primary care in Jersey as part of the transformation of the whole health and social care system. The document outlines, through robust evidence review, the best practice principles of delivering improved health outcomes, but does not mandate  how  to  deliver  them.  How  this  is  achieved  will  be  developed  in  partnership  with stakeholders (including patients, practitioners and community and voluntary sector) through options assessment, review and pilot during the planning and implementation stages.

1. What is Primary Care?

Primary Care is pivotal to the high quality, integrated holistic care provided for Islanders. It aims to maintain all Islanders in optimal health and care, for their entire lives. This includes delivering care to individuals with both acute and chronic disease, both physical and mental welfare being central to the diagnosis, management and ongoing care of patients.

From a patient perspective, Primary Care should be the first point of contact in the health and social care  system,  central  to  diagnosis,  management  and  ongoing  care;  inclusive,  that  is  available regardless of age, gender, disability, language and socioeconomic class and accessible to all, both in terms of physical access and in terms of being available, and in appropriate settings for all sections of the population.

The literature review shows that the evidence is overwhelming that health care systems configured around primary care produce healthier populations at lower cost: they are more effective, equitable and efficient.

2. The case for change

The White Paper, P82 (2012), outlined a need for the health system to change and transform. Primary care has been recognised as a key part of this change as it will ensure that care is safe, sustainable and affordable providing  more  integrated  and  holistic care  for  patients.  The  health system needs to transform because:

• The elderly population is rising disproportionately, Jersey could have as many as 28,000 people aged over 65 by 2035, compared to 14,000 in 2010 and will also see the number of people aged over 85 increase from 2,000 to 5,000
• There is a clear pattern of increasing multiple-morbidities with age in the Jersey population, with over half of the population being found to have at least one of 40 long term conditions. Existing capacity is due to be exceeded in some services across the whole health system
• Pressures  created  by  demographics  are  no  longer  affordable  using  current  funding mechanisms
• Perverse incentives built up over many years mean that patients and providers can be hindered from making correct choices
• A lack of integration reduces efficiency and damages patient experience

• There are workforce recruitment issues across the health and social care system

Change is required now to ensure that the health and social care system can continue to meet the demands placed on it and that it is sustainable for the future whilst adding value to patients and supporting them to keep well for longer.

3. The Strategy

The five ambitions of the Sustainable Primary Care Strategy are illustrated below. These have been developed with key stakeholders involved throughout the process including patients[3],[4], professionals and the voluntary and community sector[5]. The ambitions set the direction of travel for Primary Care for the next 5 years working towards improved sustainability and a safe, effective and affordable system.

Ambition 2: Payment

Ambition

Ambition 5:  1:  Ambition 3: Processes  Patients  Partnership

Ambition 4: People

1. Ambition 1: Patients

Develop an understanding of the population health needs of islanders to enable design of services which most closely meet that need. Support the people of Jersey to lead healthy lives and empower patients to understand and manage their conditions themselves.

1. The Supporting evidence from the literature

• People use markedly different amounts of health care services. The distribution of health care use across a population tends to be highly skewed, with a small number of people accounting for a large share of total resources[1]
• Around 70% of health care expenditure is for people with long term conditions[2]. Multi- morbidity is common in the Jersey population. There is a strong correlation with age, and physical and mental conditions are frequently co-morbid
• Promoting good health and preventing ill health saves money; a small shift in resource towards public health prevention activity would offer significant short, medium and long term savings to the service and to the taxpayer[3]
• Patients need to be able to access affordable primary care, and to believe that it will meet their immediate needs more effectively than the other options available to them [4]
• Better health information can have significant impacts on service use and reduce costs[5]

2. What we will do

• Develop a population needs assessment to understand the health needs of our population to support the development of targeted and needed services.
• Provide a new emphasis for Public Health initiatives within primary care to support the health and wellbeing of islanders.
• Engage with the public to better understand their needs on accessing primary care services
• Scope possible solutions to improve information and accessibility to information

2. Ambition 2: Payment

Explore payment models which incentivise outcomes but maintain the strengths of the current system.

1. The Supporting evidence from the literature

• Primary Care is a cost effective means of delivering healthcare[6]
• No one organisational model of primary care provision should be advocated. Local context plays an important role in determining organizational form, and the precise mix of function will likewise depend on the nature and priorities of the local population12

• Research suggests that too heavy a reliance on fee-for service or capitation is likely to reduce efficiency – a blend of these different approaches is most likely to strike a better balance  between  incentivising  responsiveness  to  patient  needs  and  quality  with  cost- efficiency and budgetary control 13
• Recently  published  NICE  Clinical  Guidance14  supports  the  development  of  the  roles  of primary care pharmacists

2. What we will do

• Patients and providers value the co-payment in General Practice as it gives a sense of worth to services being provided. The co-payment will continue to exist in General practice.
• Different GP payment systems will be assessed jointly with stakeholders, with the support of a Health Economist. Options will be developed and evaluated and a preferred approach taken forward which may be a blend of systems. Pilots will be run to test new payment mechanism prior to implementation.
• The Health Insurance Law has recently been amended to allow the States to enter into contracts with providers. Using this new facility the States would like to explore the option of a pharmacy contract where a range of services could be "commissioned"
• The future development of the Jersey Dental Fitness Scheme will be considered, alongside the 65+ Healthcare scheme and other dental spend
• Funding  of  community  nursing  will  be  considered  in  the  context  of  the  other  services covered in this strategy, HSSD funding, charitable funding and patient co-payment

3. Ambition 3: Partnerships

Develop more integrated working across the whole system to enable improved efficiency and safety.

1. The Supporting evidence from the literature

• "The patient's perspective is at the heart of any discussion about integrated care. Achieving integrated care requires those involved with planning and providing services to impose the patient's perspective as the organising principle of service delivery15"
• Achieving the benefits of integrated care requires strong system leadership, professional commitment,  and  good  management.  Systemic  barriers  to  integrated  care  must  be addressed if integrated care is to become a reality

12 Securing the future of general practice: new models of primary care, Judith Smith, Holly Holder, Nigel Edwards, Jo Maybin, Helen Parker, Rebecca Rosen and Nicola Walsh, The Kings Fund/Nuffield Trust, 2013

13 Reforming payment for health care in Europe to achieve better value Research report

Anita Charlesworth, Alisha Davies and Jennifer Dixon August 2012 Nuffield Trust

14 Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes, NICE, 2015

15 Integrated care for patients and populations: Improving outcomes by working together, Goodwin et al, The Kings Fund,2011

• Integrating budgets combines funds from different organisations to purchase integrated support to achieve shared outcomes. This will enable organisations to build on previous joint working experience in order to fund truly integrated care services[7].  
• In New Zealand, the development of Health Pathways' is cited as one of Canterbury's most innovative and most effective changes[8]. They are created by bringing together hospital doctors and GPs in order to discuss what the patient pathway for a particular condition should be

2. What we will do

• Assess the role of Primary Care Leadership within the Health and Social Care system as a whole, including how Primary Care continues work with HSSD along with accountability and leadership for the Primary Care Strategy
• The various funding streams within primary care will be reviewed and recommendations made to amlgamate budgets where possible, to simplify integrated working across primary care
• Develop a Clinical Forum which will be the vehicle for building closer clinical working relationships between primary and secondary care, with clinicians from the hospital and a range of primary care providers.
• Alignment between strategic developments in health and social care to support the development of multidisciplinary working with primary care.

4. Ambition 4: People

Assess and develop the primary care workforce and to provide career opportunities for people to develop the skills required to meet future challenges.

1. The Supporting evidence from the literature

• Many EU countries report difficulties both in retaining and recruiting health staff. Reasons vary between EU countries. It can be due to unattractive jobs, poor management or few opportunities for promotion[9]
• In all the case studies in the Global Health Policy Summit report[10], there was a deliberate reshaping of the workforce away from the traditional hierarchical medical model, and towards a wider skill-based team approach. This reshaping increased the capacity of the system to respond to demand, and enabled quality to be delivered at a lower cost

2. What we will do

• Conduct a workforce survey and training needs analysis across primary care in order to produce a workforce strategy to assess the options to; Develop primary-care structures to encourage the appropriate range of healthcare professionals to enter and remain in primary care sector, fully utilising their professional training; Ensure that training and CPD opportunities fully support a sustainable primary care sector

5. Ambition 5: Processes

Develop governance and IT processes to support quality, safe, and efficient delivery of care.

1. The Supporting evidence from the literature

• Brinkenhoff[11] outlines a helpful description when thinking about accountability for public services with them having three, inter-related elements: 1. Accountability for strategic decisions on provision and the allocation of resources, particularly which services are provided and to whom 2. Accountability for the quality of services delivered – such as access, clinical quality, safety and outcomes 3. Accountability for the management of resources – including value for money, probity and fairness
• The report from the International Global Forum for Health care innovators (2015)[12] stated that a comprehensive electronic record that allows data sharing across both providers and patients is the cornerstone and a key enabler for integrated working.
• In addition to providing patient records and provider performance data, technology can also benefit healthcare by improving services and delivering care remotely[13]
• The global Health Policy Summit Recommends[14] sharing information across all clinicians in contact with patients, creating transparency in primary care quality, providing transparent information to clinicians about cost and quality of specialist facility referrals and addressing information governance issues.

2. What we will do

• Continue with the current governance arrangements for General Practice. Consider expanding the existing Primary Care Governance Team in order to incorporate Pharmacists , Dentists and Optometrists
• Introduce 2-yearly patient satisfaction surveys with primary care services
• The IT systems will move towards using the JY number as the unique patient identifier in line with the e-gov strategy

• To enable this work, compulsory registration will be introduced whereby all patients will have to register with a preferred GP practice. Patients will still be allowed to move or change between practices
• The Informatics Strategy[15] states a number of aims for developing integrated record sharing between primary and secondary care. We will support these aims and ensure Primary Care is prioritised

4. Implementation Plan

The strategy has been developed in collaboration between government departments (Health and Social  Services  Department  (HSSD),  Social  Security  Department  (SSD)  and  Treasury)  and  key stakeholders including provider groups across primary care, community and voluntary and patient groups. This will continue to be the case through the development and assessment of options and piloting to understand how these options work in practice.

The process of approval will see the strategy presented to politicians at the Ministerial Oversight Group, and the Council of ministers during the Autumn of 2015. If approved, a public communication will be held to gather views on the strategy to support the planning phase. The implementation of the  strategy  will  take  the  full  time  period  of  the  strategy  to  2020  and  changes  will  not  be implemented before being thought through, assessed and tested.

Planning  

Implementation

SPC

Strategy  Options  Pilot

Transition to SPC Implementation Plan  Business as

Usual

Autumn 2015   2020

[16]3  Introduction and Background

1. What is Primary Care?

Primary Care is pivotal to the high quality, integrated holistic care provided for Islanders. It aims to maintain all Islanders in optimal health and care, for their entire lives. This includes delivering care to individuals with both acute and chronic disease, both physical and mental welfare being central to the diagnosis, management and ongoing care of patients. Traditionally, it is defined as "services provided by GP practices, dental practices, community pharmacies and high street optometrists". However, other services can also be classified as primary care' such as District Nursing and Health Visiting.

From a patient perspective, Primary Care should be the first point of contact in the health and social care  system,  central  to  diagnosis,  management  and  ongoing  care;  inclusive,  that  is  available regardless of age, gender, disability, language and socioeconomic class and accessible to all, both in terms of physical access and in terms of being available, and in appropriate settings for all sections of the population.

The World Health Organisation Declaration of Alma-Ata (1978)

"Primary health care is essential health care based on practical, scientifically sound and

socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community

and country can afford to maintain at every stage of their development in the spirit of self- reliance and self-determination."

25

Primary Care is the gatekeeper for community and secondary care services. Primary Care staff are the  lead  professionals  for  supporting  self-care,  self  management,  health  promotion  and  health education  as  well  as  making  sure  that  the  patient's  needs  remain  central  to  their  treatment, ensuring that treatment is always appropriate and that care is planned and co-ordinated.

3.1.1 Features of an effective primary care system from the Literature

Strong and effective primary care is typically considered to be critical to a high performing health care system because of its role in improving outcomes and containing costs[17],[18]. Recent research has concluded that strong primary care is associated with lower rates of avoidable admissions to hospital

and fewer potential years of life lost for most of the conditions that were studied; yet requires higher levels of health spending to achieve such benefits, with likely savings accruing in the longer term[19]. The evidence is overwhelming that health care systems configured around primary care produce healthier populations at lower cost: they are more effective, equitable and efficient. Current models of healthcare focused on hospitals as the main location for care giving, are unsustainable. Chronic diseases are already the major cause of death across the world and the impact is set to worsen by 2030[20].

"In England an increase of 1 primary care doctor per 10,000 population is linked to a 6% decrease in mortality[21]"

Ten priorities for action were identified by a Kings Fund report in 2010 for transforming our health care systems[22]. A striking feature of all the priorities is the degree to which they call for change within primary care and the way in which primary care relates to the rest of the system.

A recent report from the Nuffield Trust outlined what an effective primary care would look like[23]. It should be comprehensive, Person-centred, population oriented, coordinated, accessible, safe and of high quality:

• Primary Care co-ordinates the care of many people with multiple complex health needs in a way that individual specialists cannot. It delivers care closer to people, increasing convenience; is a first point of contact for patients and facilitates the early detection of illness and thereby improved outcomes. Primary Care also takes a long term perspective to support prevention and healthy lifestyles
• Primary Care practitioners are critical to understanding the needs, preferences and social circumstances of the individual (and, where appropriate, their carers and families) and making sure the patient is at the centre of care delivery
• Primary Care must work as a true partner in multidisciplinary teams, with trusted professional relationships and mutual respect, supported by shared information and decision making
• Primary Care must be sustainable, with the most appropriate workforce and skill mix working effectively and in particular, with funding systems that offer fair reward and encourage and incentivise the right behaviours from both patients and clinicians

2. Measures of health system performance

In The Commonwealth Fund: Mirror, Mirror on the Wall (2014) [24] report, 80 indicators of health system performance are grouped into 5 dimensions of performance as seen in figure 1.

Figure 1: Internationally recognised health care comparator measures

As shown in Figure 2, the U.S. ranked last of 11 nations overall. Findings in this report confirm many of those in the earlier four editions of Mirror, Mirror, with the U.S. still ranking last on indicators of efficiency, equity, and outcomes. The U.K. continues to demonstrate strong performance and ranked first overall, though lagging notably on health outcomes. Switzerland, which was included for the first time in this edition, ranked second overall.

Figure 2: Comparison of health care systems from around the world

3.2.1 Measuring Outcomes of the strategy

It is proposed that these five dimensions of performance are used to assess how the implementation of the strategy will benefit the patients in the Primary Care System. Indicators will need to be developed  that  would  be  monitored  to  show  progress,  as  well  as  identifying  gaps  in  data  or information  that  need  to  be  developed  for  ongoing  monitored.  During  the  first  year  of implementation, a baseline measure against these indicators would need to be taken in order to benchmark progress both internally and allow international comparison. It is also proposed that an external Body would measure success against these indictors on a 3 year basis.

Figure 3 highlights the relationship between spend and quality of outcomes in Small Islands[25]. The trend line shows the expected relationship between cost per capita and average life expectancy at birth. Those jurisdictions falling below the curve could improve the value they derived from their healthcare expenditure. The trends seen on a global scale indicate that those countries who spend very little on healthcare can see significant improvements in outcomes by spending more (i.e. there is a steep rise at the far left of the curve). (Jersey - JEY on the graph).

Figure 3 Healthcare spend per capita against average life expectancy at birth

3. The White  Paper:  A  New  Way Forward  for  Health  and Social Care (P82) (2013 – 2021).

In  common  with  jurisdictions  and  countries  across  the  world,  Jersey  faces  substantial  current challenges in ensuring the availability of high quality health and social care for its citizens within a financially  affordable  sum.  A  New  Way  Forward  for  Health  and  Social  Care'  (P82,  2012), demonstrated that health and social care services in Jersey were at a crossroads. Existing capacity was due to be exceeded in some services, the elderly population is rising disproportionately and almost 60% of the medical workforce is due to retire in the next 7 years. P82/2012 clearly stated that services must be safe, sustainable and affordable. This was debated in the States in October 2012, and endorsed.

The States Strategic Plan 2015 – 18[26] clearly outlines the objective of the Council of Ministers to promote health and social wellbeing for the whole community, providing prompt services for all and protecting the interests of the frail and the vulnerable'.

This provides ongoing focus and support for primary care as part of a redesigned health and social care system.

3.3.1 Sustainable Primary Care Project Board

In order to develop and deliver a primary care strategy as part of the overall States objective, a Sustainable Primary Care Project Board was set up in 2014 with a wide ranging membership:

Table 2: Membership of the Sustainable Primary Care Board

The Project Outcomes and Objectives were:

Develop a strategy to deliver the optimal blend of payments and outcomes in Primary Care, to incentivise health seeking behaviour and appropriate resource use across the whole system in States of Jersey.

This scope for the project was endorsed by the Ministerial Oversight Group on 21st July 2014. The Sustainable Primary Care project outcomes were to deliver:

• A strategy which integrates Primary Care into the transformed health and social care system
• An agreed proposed model for safe, sustainable and affordable Primary Care
• A proposed preferred approach for contractual and governance mechanisms to deliver the agreed Primary Care strategy

The  Sustainable  Primary  Care  Project  Board  is  one  of  three  programmes  that  forms  the transformation plan for the health and social care system and formally reports to a Ministerial Oversight Group, as shown in Figure 4.

Various Task and Finish/Working groups- individual project and cross cutting

Figure 4: Overview of the integrated strategic context

In developing this strategy, consideration has been paid to a number of policy and reform objectives and imperatives. Figure 4 shows the boundary of the sustainable primary care strategy, and how parallel strategies are delivering change across the whole of the health and social care system in line with P82/2012 principles. A short summary of the relevant areas is set out in Table 3 below. It is not an exhaustive list but is intended to provide a broad view of the strategic context.

Table 3: Alignment with Other Strategies

Primary care is different from other areas of health and social care in that it is mainly provided by non-States organisations. The primary care strategy is a co-production between those organisations and The States and relies on both sides working together to develop sustainable primary care facilities in Jersey that support and are supported by other areas of health and social care provision which are funded directly by the Government.

A key foundation of the new strategy is that this situation will continue and non-States organisations will carry on exercising considerable autonomy in the services that they provide and how they choose to provide them.

The purpose of this document is:

• To set a strategic direction for development of the sustainability of primary care services for the future and within the new Health and Social Care System vision
• To outline how primary care will be delivered against quality, access, efficiency, equity, healthy lives criteria
• To describe the current situation in Primary Care and make the case for change
• To review the literature in order to set the context of the strategy within international evidence and best practice
• To gather views and the voice of stakeholders including patients, professionals and the voluntary and community sector

4  Structure of the Current Provision of Primary Care

Services in Jersey

1. Profile of Primary Care Providers in Jersey

The current health system in Jersey is based on 1960's laws which have not changed significantly but have been progressively amended. This system has served Jersey well delivering good quality care for  many  years,  however  the  model  of  provision  is  based  on  individual  contractors  with  little integration and provides incentives which reward reactive rather than proactive care.

The system funding and activity is illustrated in Figure 5 and a description of services provided is in Table 4.

Health Insurance Fund (HIF)

JQIF  Pharmaceutical Benefit Average £6.44 per item

£3.37 fee per item dispensed Provision of GP  Provision of

Services  Pharmacy Services

Medical Benefit

Childhood No charges for

  £20.28 per

Immunization  consultation   PrOpotovisimoentr oyf

prescriptions

6 week check  Patient  Services

Provision of

Nursing Services  Provision of

Dental Services

Health and Social Services

Figure 5: Overview of the funding model and activity within Primary Care in Jersey (2013 figures)

Table 4: Descriptions of services for Primary Care provider groups

37 OECD (2011) stats in: An analysis of the dental Workforce in Wales; National Leadership and Innovation Agency for Health Care, 2012

2. What Works well in Jersey and What has been Achieved?

There are a number of very positive features within the current system that we need to maintain in order to ensure the best possible value for islanders is delivered through the health and social care system.

1. General Practice

Primary care providers, as independent businesses, value their freedom to respond to customer needs without complex contractual restrictions. As reported by the Jersey Consumer Council[1], patients value the continuity of seeing the same doctor in primary care, with the majority of primary care facilities being very good. Telephone advice is readily available across all GP practices and is free of charge. Patient access to see a GP is good and appointments can usually be made on the same day. Patients are usually able choose to see their own GP, with many having built up family relationships over a number of years with their practitioner who provides holistic care.

2. Formation of Primary Care Governance Team

The Primary Care Governance Team (PCGT), formed in 2012 is a small team whose role is to provide governance of General practitioners ensuring practices offer the very best standards of patient care. Their role includes the following:

1. Revalidation and GP performers list

In October 2014, the Health Insurance (Performers List for General Medical Practitioners, Jersey Regulations 2014) was introduced, alongside revalidation for GPs, the Performers List and changes to the registration process. This was a significant step, and one which will help ensure confidence from the General Medical Council, and from patients, regarding the quality of general medical practice care  in  Jersey.  At  the  same  time,  the Medical  Practitioners  (Registration)  (Responsible Officers) (Jersey) Order 2014 was also introduced setting out the responsibilities of the Responsible Officer.

2. Complaints Process in General Practice

There is a robust complaints process in place to investigate complaints and the Health Insurance (Performers List for General Medical Practitioners) (Jersey) Regulations 2014 has established a formal process by which concerns about a GP can be addressed. The Primary Care Governance Team will undertake investigations into complaints and concerns and respond within 28 days. There may, on occasion, be a requirement to refer a complaint to an external agency for investigation. Such referrals would usually be made to a specialist investigation team co-ordinated and led by NHS England (Wessex Area Team) but may also be referred to the National Clinical Assessment Service (NCAS) or, in more serious cases, to the appropriate regulator, usually the General Medical Council (GMC).

3. Jersey Quality Improvement Framework (JQIF)

Jersey has adopted a Quality Improvement Framework (JQIF), and this has been embraced as an effective mechanism for incentivising GPs, alongside the reshaped rebate. This has resulted in co- ordinated collection of data which should lead to improvements in the care offered to our patients and is a foundation for developing the quality agenda in years to come. Currently JQIF provides payment based on list size, recording clinical indicators and for demonstrating that the practice is working towards standards in practice organisation. The clinical indicators are agreed with local GP's and based on indicators from UK Quality Outcomes Framework (QOF) whilst the organisational indicators are bespoke to Jersey.

4. EMIS IT System in Primary Care

EMIS Web is the patient information system used across all Jersey GPs including Jersey Doctors On Call' (JDOC) who provide the Out of Hours Service. EMIS is also used by the Health Intelligence Unit and the Primary Care Governance Team to support Jersey Quality Improvement Framework (JQIF). This will provide accurate disease registers that will in turn, inform health service planning.

Work is in progress to roll out EMIS Web to other services in primary care which will further enhance patient quality of care.

5. Childhood Immunisation

There are two contracts for services, placed by the Public Health Department, for specific immunisation programmes and screening within primary care, namely the childhood immunisation programme and the six week infant development check. The six week check is funded through a payment to the practice for each developmental check performed and outcome results received. Childhood immunisation is funded through a quarterly payment to the practice for each immunisation consultation (known as an immunisation visit') performed in accordance with the Jersey has a high coverage of childhood immunisations, consistently higher than the average reported for England and for immunisation given at 2,3,4 and 12 months of age, coverage is above the World Health Organisation target of 95%[2].  

6. Dentists

The epidemiological survey in March 2014, reported that the oral health of the children reviewed was generally good and comparable to regions in England with the highest levels of good oral health. As in previous years there was disparity in the level of dental health between schools.

7. Pharmacists

In January 2013, pharmacy based smoking cessation services were launched under contract with Health and Social Services Department. Initial funding enabled smokers to access five support sessions with the provision of single nicotine replacement therapy (NRT). For the period April 2013 to March 2014, 871 smokers set a quit date and 35% were quit after four weeks. In January 2014, additional funding was approved by the health minister, enabling the service to gradually expand to its current level of service provision; nine support sessions with dual NRT offered for up to 12 weeks. The enhancements to the service are now aligned with best evidence for smoking cessation. During the period April 2014 to March 2015, 754 smokers set a quit date with a 42% quit rate achieved at four weeks. The reduction in numbers may possibly be attributed to a rise in the use of vapourisers and this has also occurred in UK services. However, the quit rate for 2014/2015 was higher than in the first year and represents an outcome of the enhanced service provision and an increased level of competency in delivering cessation support.

8. Optometrists

The nature of working on a small Island has led to a profession that works and interacts very well together. Information, such as patient prescriptions or GP referral letters can be easily sent to other practices upon request with more using email for speed and convenience. There exists a very good relationship between Optometrists, GP's, the Eye Department, Consultants privately and the Orthoptic Department. The private industry within Optometry has enabled the profession to offer above UK standard of care with better equipped practices i.e. all have fundus cameras', some now invested in Optical Coherence Tomography (OTC) and many conduct digital dispensing.

9. Nursing

Family Nursing and Home Care (FBHC), are the only provider of general community nursing on the Island. The services are commissioned through a Service Level Agreement (SLA) with HSSD. There are areas of good joint working with other charities and state departments. There is an ability to develop new initiatives such as the implementation of the Gold Standard framework to improve patient care.

10. Out of Hospital Care

The aim of the Out of Hospital system and services is to ensure that many more people will have increased independence and the choice of being cared for in their own home for as long as possible. This is achieved by delaying or reducing the need for entry into long term care, avoiding hospital admission where clinically appropriate and facilitating early transfers of care from hospital. Patients will experience a person-centred care approach that is delivered by a range of professionals in well- co-ordinated, integrated, multidisciplinary team(s). The focus of care will be on achieving agreed outcomes, for patients, for the service and for the whole system.

The provision of community nursing services in Jersey up to 2014 has been through traditional models of District Nursing and Home Care services therefore Out of Hospital care has required a new approach, enabling the opportunity for clinical staff to influence the development of the services, to be creative and innovative and to ensure that the services are responsive and delivered by the right person in the right place at the right time. The contract to provide the Step Up /Step down service has been awarded and commenced in May 2015.

5  Why Do We Need to Change?

The Global Health Policy Summit in its report "Primary Care, the Central Function and Main Focus"[3] identifies seven Common issues faced by primary care across the world. Some, but not all, are reflected in our own Health and Social Care system in States of Jersey to varying degrees:

1. Poor patient access and perceptions
2. Insufficient coordination and integration
3. Low professional prestige and limited availability of the workforce
4. Lack of infrastructure investment
5. Misaligned incentives
6. Under-utilisation of information and technology
7. Variable quality standards and regulation

The following are the main drivers for the need to change in Jersey:

1. Funding Options for Health

In 2011 KPMG were commissioned to explore the funding options available to the States of Jersey, drawing on their international database of knowledge and experience of existing Health funding methods  in  countries  such  as  Singapore,  the  Netherlands,  the USA  and  Guernsey.  Their  report highlighted  the  three  main  types  of  policy  options  available:  insurance  contributions  (either mandated or through encouraged private insurance), taxes and charging health care users to pay at the point of delivery.

There are a number of practical policy variations and considerations around these mechanisms, and whilst all options have their respective benefits and drawbacks, ultimately the gap is most easily bridged by the public of Jersey making a greater contribution in funding, or electing to reduce services elsewhere. KPMG made a recommendation that they reached based on analysing existing literature on health and social care financing methodology in other jurisdictions around the world, consultations  with  health  and  social  care  and  financing  experts  from  within  the  Global  KPMG network, as well as direct discussions with stakeholders in Jersey as to what is feasible in the local environment.

In 2014 The Kings Fund commissioned a review[4] into people's entitlement to health, care and support and how these could be funded. The report expressed their view that there should be a "single  ring-fenced  budget  for  health  and  social  care  which  is  singly  commissioned  and  which entitlements are much more closely aligned". Jersey is ahead of the UK in this respect, we already

have this in place. However, we are facing the same issues as the UK in terms of affordability of a 21st century health and social care service. The King's Fund report also acknowledges there are some

hard decisions to be faced with regards to funding, that there will be a requirement of a combination of higher taxation, charges or cuts in other areas of public spending. They also suggest that some of the funding should come from a pensioner population that is on average better off than its preceding cohort.

With the political support in place, an officer group was convened, with representatives across all areas of the States affected, with a remit to look at how the gap might be funded. Any solution should aim to provide a mechanism that provides funding for primary care, increases in secondary care and the demographically driven changes.

When making a decision as to how the additional health and social care costs should be funded certain characteristics of the system are key:

• Equity – The system must be fair. People in similar circumstances must be treated equally with those best able to bear the burden making the largest contribution
• Efficiency – The system must be easy to administer
• Simplicity – The system must be easy for the public to understand
• Predictability – The public must know what they will have to pay in the short and medium term without unexpected changes

A proposal (Figure 6) to fund the priorities has been put forward including the introduction of a health charge by 2019.The charge is likely to be introduced in a phased way with the £35 million target by 2019 at the latest. The solution will need to be cognisant of the Fiscal Strategy and may be a mix of new contribution charges for individual as well as point of service charges.

Proposals to Fund the Priorities:  2015-2019

HEALTH  £35 m SUSTAINABLE FUNDING FOR HEALTH CHARGE • Introduced by 2019

SNTONAFF- £40 m N••• OSGrOtNoh-acSeniaTrtls A NS aFF oenncd-uS SsrAitutayVbf fIsb NciedoGnieseStsfsits

• User pays / charges

PEOPLE

• Pay restraint

• Vacancy management

PEOPLE £70 m • VR/CR

• Performance management

• Service redesign – LEAN / eGov / mergers

• Outsourcing

• Regulation

• Stop doing

Figure 6: States of Jersey Proposals to fund strategic priorities 2015-2019[5]

2. Strategic Planning and Population Policy

The White Paper A New Way Forward for Health and Social Care', (P82/2012)[6] demonstrated that health and social care services in Jersey were at a crossroads. Existing capacity was due to be exceeded in some services, the elderly population is rising disproportionately and almost 60% of the medical workforce is due to retire in the next 7 years.

Figure 7 shows that Jersey is facing demographic challenges in the years ahead. More people are reaching retirement age and people are living longer. In 2014, there were more pensioners living in Jersey than ever before and the total number of deaths in the Island was the lowest since 1952. This is something to celebrate, but we must also plan and prepare. The population projections produced by the States Statistics Unit highlight that[7]:

• We could have as many as 28,000 people aged over 65 by 2035, compared to 14,000 in 2010
• We will also see the number of people aged over 85 increase from 2,000 to 5,000

Figure 7: Predicted population demographic change in Jersey between 2010 and 2040 based on +325 net inward migration

In addition, the decrease in number of working age' people will produce:

• Reduced income tax
• Decreased available workforce able to support increasing care needs
• Even more pressure on carers

The demographic pressures place additional demand on both hospital and community services but also change the nature of the service, placing more emphasis on the need for prevention, long term management, developing new models of care and taking advantage of advances in technology.

3. Increasein Number and Complexity of people with Long Term Conditions

"A long term condition is one that cannot currently be cured but can be controlled with the use of medication and/or other therapies"[8]

Not only is the population changing, but the profile of the population is changing too as can be seen in Figure 7. One of the main challenges facing health systems and governments today is the rising prevalence of long term conditions in patients, especially multi-morbid patients (i.e. patients with two or more long term conditions) who use more inpatient and ambulatory health and social care than people who suffer from a single condition. A great success story of modern health care systems is that people are living longer; however, this means that they are also living with more and more long- term conditions, meaning that people will have a greater need for health care. In a report from England[9], it was found that multi-morbidity, specified by different measures,  consistently shows a significant and positive association to health service use in terms of GP visits, outpatient visits and number of nights spent in hospital. People with two or more long term conditions use health services more than people without multi-morbidity.

However, in Jersey disease registers are at a very early stage of development, which has made it hard to understand the prevalence of long term conditions and how many of our population are living with two or more long term conditions. This also means we have had very little data about our population health in order to support decision making to support integration of services. This has made it difficult to design services to best meet patient need. However, more recently the impact of multiple morbidities on the Jersey GP registered population has been investigated using the new GP central server. This has allowed population wide data to be examined for the first time. There is a clear pattern of increasing morbidities with age in the population, with over half of the population being found to have at least one of 40 chronic conditions. Health Intelligence have produced some preliminary  data  showing  the  extent  of  multimorbidity  in  Jersey  (2015).  Figure  8  shows  Jersey distribution of multiple conditions within the population using data for 40 common long –term conditions.[10]

100%  80%  60%  40%  

20%  0%  

00-09  10-19  20-29  30-39  40-49  50-59  60-69  70-79  80-89  90-99

Fig 8: Shows Proportion of population with at least 1 chronic condition by age group (based on 40 condition study)

4. Acute Hospital Care in Jersey

Acute hospital care is expensive. It costs around £550 per day to stay in Jersey General hospital. Inpatient spells are projected to increase by 33% by 2040. This increase in activity will lead to a more significant need for Hospital medical beds – a projected increase of 25% by 2020 and 72% by 2040. This significant increase in demand for hospital beds will mean that hospital capacity is insufficient within the current model of health and social services, and will start to be exceeded in the very near future. In 2013 there were 6,918 non-elective hospital admissions. 3,153 of these were for people aged over 65, of which 2,219 were medical. Primary Care needs to be able to adapt to the increasing long term conditions and demographic bubble.

5. Perverse and Misaligned incentives

Table 5: Description of perverse incentives identified

6. Information (IT) and Data Across Primary Care

EMIS Web is the patient information system used across all Jersey GP's including Jersey Doctors On Call' (JDOC) who provide the Out of Hours Service. EMIS is also used by the Health Intelligence Unit and the Primary Care Governance Team to support Jersey Quality Improvement Framework (JQIF). This will provide accurate disease registers that will in turn, inform health service planning.

Work is in progress to roll out EMIS Web to other services in primary care and the community such as Jersey Talking Therapies, FNHC and Jersey Hospice, which will further enhance patient quality of care.

5.6.1 What are the problems with the current IT and Data collection systems?

There is a system issue in that none of the IT systems link i.e. EMIS IT system has no direct link to either the hospital IT system, the social care IT system nor to dentists, optometrists and pharmacists. The IT systems used by Dentists, Optometrists and Pharmacists are independent of any other systems. There are several differing IT systems within each of these contractor groups.

This means that there is no consistent information transfer mechanism between providers. Most practices store all patient information electronically and much of this is scanned from paper copy letters received from a range of other providers. The acute hospital system is still mainly using paper records. Some departments within the hospital accept electronic referral forms while others require a letter. This is not an efficient system for patients or providers.

There is very little collection of high quality data to support decision making and where there is data, it is not collected and analysed centrally to support integration of services. This makes it difficult to design services to best meet patient need. This is supported by the fact that the central disease registers in Jersey are at a very early stage of development which is making it hard to understand the prevalence of conditions.

Where data does exist, although there is strong information governance protection, there are few information sharing agreements to allow that data to be shared for the benefit of patient care, preventing a holistic view of the health needs of the population to support development of services relating to need.

7. Clinical Sustainability of Primary Care

There are workforce issues in particular across General Practice, Pharmacy and Nursing in Jersey. Specifically there are issues are around recruitment and maintaining a skilled workforce as shown in Table 6.

Table 6: A summary of the workforce issues across the professional groups

8. Integration

The  White  Paper  noted  that  there  is  limited  integration  with  secondary  care,  social  care  and Voluntary and Community Sector provision. Once patients are referred to another service, the GP is often excluded and does not always receive ongoing follow up details. This makes it difficult for the GP to provide holistic, co-ordinated care. Lack of co-ordination can result in a poor experience for the patient and costly duplication. Teams are not fully integrated or embedded in Primary Care. There is limited hosting of services within practices, and District Nurses and Health Visitors are not attached to GP practices or co-located. This means that all the practitioners are isolated.

9. The Case for Change: Conclusion

Therefore in summary, the ageing population along with the rise in patients with two or more long term conditions, the difficult financial climate, lack of joined up IT and data systems, the concerns around the sustainability of our primary care workforce, perverse incentives across the health and social care system, poor understanding of our population health needs and lack of integration across the whole system, supports the Case for Change'. We need a new model of sustainable primary care in Jersey that forms part of an integrated approach, within the new Health and Social Care System.

Therefore, change is required now to ensure that the health and social care system can continue to meet the demands placed on it and that it is sustainable for the future whilst adding value to patients and supporting them to keep well for longer.  

10. What are the implications of doing nothing?

Table 7 outlines the implications of doing nothing across the contractor groups and systems

A new approach to primary care is needed that will need to be safe, sustainable and affordable offering value for money for taxpayers and Islanders.

6  Detail of the Strategy

1. The 5  Ambitions  of  the Sustainable  Primary  Care Strategy in Jersey

The five ambitions of the Sustainable Primary Care Strategy are illustrated in Figure 9. These have been developed with key stakeholders involved throughout the process including patients[2],[3],[4], professionals[5] and the voluntary and community sector[6]. The ambitions set the direction of travel for Primary Care for the next 5 years working towards improved sustainability and a safe, effective and affordable system.

The ambitions will impact on patients, the different professionals and services in different ways. The ambitions will be confirmed and expanded as the model develops during the 5-year implementation phase.  All  stakeholders  will  continue  to  be  involved  throughout  development  of  detail  and implementing the direction of travel to ensure that the implementation is the best solution for Jersey.

Ambition 2: Payment

Ambition

Ambition 5:  1:  Ambition 3: Processes  Patients  Partnership

Ambition 4: People

Figure 9: The 5 Key ambitions for Primary Care in Jersey.

2. Ambition 1 – Patients

1. Outline of Ambition

Ambition 1 is the central theme of this strategy and focuses on delivering better outcomes for patients. This means putting our patients at the heart of care delivery. Enabling the people of Jersey to  lead  healthy  lives  and  empowering  patients  to  understand  and  manage  their  conditions themselves. This will be achieved through us understanding patient needs and developing service packages to wrap care around the patients and to better meet their needs.

2. Emerging themes from Professional Workshops

• Patients need to be able to access affordable primary care and believe that it will meet their needs more effectively than other options available to them
• Access should be more closely related to need rather than ability to pay
• There should be a greater emphasis on health promotion and prevention and a greater responsibility for self care
• Government policy should shift care from secondary to primary
• HSSD will use data to identify population needs and drive up performance

Patients will be encouraged to use ICT to manage and improve their own care

3. Patient Voice

On Access:

 "difficult to find where the health visitor clinics were- even the GP didn't know"

There was very poor knowledge of the children's dental scheme for under 12's and concerns about the long wait to be seen by the dentist

There was mixed awareness about the JDOC service out of hours:

"no transparency, no terms and conditions and no notification of price rise"

Issues about sources of information:

"lack of information online- people are IT savvy so would use it"

"more opening times in different parishes as some people need chemist and cannot get to them" "need for more recognition of carers and the development of a Carers strategy would help this"

4. Principles

• Understand local health needs by collecting local health data across all health sectors
• This local data will be used to identify groups that need additional support and primary care services will be developed to reflect these needs
• Primary care services will be developed with the patient at the centre so that patients, families and carers receive care in the way that is important to them
• Defining the value of healthcare around outcomes that matter to patients including health and wellbeing
• Primary  care  services will  be  developed  with  a  focus  on  patient  outcomes  and  patient reported quality
• Primary care services will be developed with a simple structure, clearly linked to other parts of the health system and information about all aspects of healthcare will be easily accessed by the general public and practitioners
• Primary care services will emphasise health promotion and individuals will take on more responsibility for maintaining a healthy lifestyle

5. The supporting evidence from the Literature:  Understand the needs of the population

People use markedly different amounts of health care services. The distribution of health care use across a population tends to be highly skewed, with a small number of people accounting for a large share of total resources as illustrated in the Kaiser Permanente ModelFigure 10. This distribution has important implications for how preventive services are targeted, how budgets are set, and how health services are regulated and evaluated.

Figure 10: Assessment of segmented population healthcare usage[7]

Health care providers around the world are now using data to understand their population needs[8]. Data is collected from a variety of sources and linked. This linked data is then run through software to determine, based on current need, what the needs of patients will be for the next 12 months. Services are then targeted based on predicted patient need. This process is called risk stratification.

1. Long Term Conditions (LTC)

Due to the increase in proportion of older people in the population, the number of people living with a single or multiple long term conditions will increase.

Definition

"A long term condition is one that cannot currently be cured but can be controlled with the use of medication and/or other therapies.[9]"

In total it is estimated by Department of Health in the UK[10] and by Kings Fund[11] that around 70% of health care expenditure is for people with long term conditions. The issue will only get worse as the demographic  change  increases  the  proportion  of  people  aged  over  65.  Figure  11  shows  the proportion of people with one or more long term conditions in Scotland. The Department of Health estimates that although the number of people with one long term condition will remain fairly stable, the number with multiple long term conditions will increase.

Figure 11: Proportion of long term conditions by age in Scotland[12].

The burden of disease is reflected in Figure 12 showing the percentage of people with one long term physical or mental disorder that also have another one or more long term conditions.

Figure 12: Percentage on patients with one long term condition who also have another one or more long term conditions 30

In Jersey, further analysis was carried out by the Health Intelligence Unit across 40 conditions based on Professor Stewart Mercer et al work30 and is shown in Figure 13. Further work is needed to

consider whether these are the 40 most appropriate conditions for our Jersey population as these were based on a Scott ish population.

40 condition study

Coronary heart  disease

Diabetes COPD Cancer

9% 9% 6% 3% 4% 6% 39% 17% 15% 1%

Public Health Intelligence Unit

Figure: 13: Shows selected co-morbidities in people with 4 common disorders in Jersey.

These results indicate that multi-morbidity is common in the Jersey population. There is a strong correlation with age, and physical and mental conditions are frequently co-morbid. This work is the first look at multi-morbidity in the Jersey population and is the foundation to further work to map the burden on the population. The findings fit the pattern of multi-morbidity found in Scotland by the 2012 Lancet30 study that this work is based on. Replicating these finding for Jersey raises similar questions  to those  being addressed  by the  health care system  in  Scotland, but  also  raises  the question of whether there are other chronic conditions that affect the Jersey population that have not yet been considered and this is where the focus of future work in this area should first start.

The model below in Figure 14, illustrates that approximately 70% - 80% of people living with a long term condition are supported by mainstream services or manage their own condition; 20% – 30% of people would be regarded as at risk of exacerbations leading to unplanned hospital admission, and the  remaining  (approximately  5%)  patients  are  highly  complex  and  require  additional  support through specialist teams in order to manage their condition and maximise potential for independent living.

Population model

Care

Management LeComvepl l3ex co-morbidity

3 – 5%

Disease Level 2

Management Poorly controlled single

disease 15 – 20%

Level 1 Supported  Well controlled

Self Care (70-80% of LTC population)

Population Wide Prevention, Health Improvement & Health Promotion

Figure 14: population model for Long Term Conditions Management[13]

2. Integrating  the  management  of  patients  with  both  mental  and  physical

health needs

This means developing a more integrated response to people with both mental and physical health problems,  in  particular  supporting  people  with  common  mental  health  problems  (such  as, depression or anxiety) alongside a physical long-term condition37. At least half of all people with long-term conditions suffer from multiple co-existing conditions. Mental health problems are one of the most common forms of co-morbidity, particularly among people from the most deprived population groups.

Mental health problems interact with physical health and can trigger or severely exacerbate other conditions. For example, depression has been associated with a four-fold increase in the risk of heart disease and a three-and-a-half-fold increase in mortality rates after heart attack[14].  

Between 12 and 18 per cent of all NHS expenditure on long-term conditions is estimated to be linked to mental health problems. Across a range of conditions, each patient with co-morbid depression costs health services between 30 and 140 per cent more than equivalent patients without depression. Unidentified mental health problems often underlie medically unexplained symptoms', which cost the NHS around £3 billion each year and cause significant distress to patients. Improving the way we respond to co-morbid physical and mental health problems would have a high impact in terms of patient experience and clinical outcomes, since both of these are substantially poorer relative to those for people with a single condition.

6. What We Will Do: Understand the needs of the population

1. Develop a population needs assessment

It is important that we understand the needs of our population so that services can be designed and targeted to meet these needs. Organisations across the health and social care system in Jersey collect and handle vast amounts of data about patients. Information will be collected, linked and processed across the Whole Health System in order to understand the historical health needs of the population of Jersey. This assessment will then be used to predict future health needs for two specific reasons:

• To support funding services based on predicted future need, derived from an understanding of the current and historic patient needs
• In the near future, to support identification and proactive intervention with patients identified as high risk of requiring intense care

The Dental Review (2015)[15] recommended that a needs assessment be conducted, offering better intelligence on the demands placed on Jersey's oral health system. While the value of epidemiology surveys was questioned, the review identified opportunities to collect information by recording the oral health of children examined as part of the Community Dental Service school visits. Further opportunities may be found in the school survey conducted by Education among children in years 6, 8 and 10.

2. Strengthen Data Governance

The collection and exchange of data will be carefully controlled and managed within the relevant information governance laws. A regulation, to be approved by the States, will be developed against Schedule 3 of the Data Protection Act to provide the democratic mandate to process the data.

The population needs can typically fit into one of 3 categories as shown in Figure 15. This data will provide information on disease prevalence, social determinants and activity. This will support the design of new systems of care delivery. There is an inverse relationship with demand on health services, with the complex 5% using a lot more services than the healthy majority.

Prevention & wellness  Supported Self Care  Condition Management promotion  15- 35% population  5% Population usually with 60- 80% population  complex diseases, co-

Avoid unnecessary higher- morbidities

Keep People healthy and  intensity, higher cost

connected to the system  spending  Trade high-cost services for

low cost management

18% of rising risk patients

become high risk annually

Figure 15: Categories of population needs

3. Define vulnerable groups

The WHO pinpoints four different ways that a vulnerable population lacks equity: economically, socially, demographically, and geographically. More often than not, a combination of these four factors contributes to inequitable health care. De Chesnay41 adds to this by defining vulnerable groups  as  having  greater  than  average  risk  of  developing  health  problems  because  of  their marginalised social status, limited access to economic resources, or personal characteristics such as age and gender[16].

Once the health needs of the population have been established, a definition of vulnerability can be set.  The  definition  will  be  multi-dimensional  based  on  clinical,  financial  and  social  need.  This definition will allow vulnerable groups within the population to be identified and care to be targeted to support these groups. Targeted support will have to take cognisance of the capability and capacity to provide services, such as the extent of available budgets, which will involve political input and decision making. The definition will reviewed periodically and will be updated as required as the population needs change and evolve. This will be carried out in a framework that is safe, sustainable and affordable in Jersey.

7. The supporting evidence from the Literature: Promote Prevention and Well Being

General practice is the cornerstone of primary health care, with population health and well being described as one of its key pillars[17]. Improving health and well being has a very wide scope and many of the determinants of health are, of course, not under the direct control of general practices.

"Promoting good health and preventing ill health saves moneya small shift in resource towards public health prevention activity would offer significant short, medium and long term savings to the service and to the taxpayer"[18]

Action is required now to reduce the incidence of disease and health problems within the population, either through universal measures that reduce lifestyle risks and their causes or by targeting high-risk groups. The World Health Organisation (WHO) has estimated that seven risk factors; tobacco, alcohol, low fruit and vegetable intake, physical inactivity, high blood pressure, high cholesterol, overweight and obesity account for 60 % of the disease burden in Europe[19]. A major review of the quality of general practice conducted by The King's Fund in 2011[20] concluded that: