Governance Arrangements within Health and Community Services: six-monthly update report pursuant to the Comptroller and Auditor General’s Reports R.120/2018 and R.42/2019, with comments of the Public Accounts Committee

STATES OF JERSEY

r

GOVERNANCE ARRANGEMENTS WITHIN HEALTH AND COMMUNITY SERVICES: SIX-MONTHLY UPDATE REPORT PURSUANT TO THE COMPTROLLER AND AUDITOR GENERAL'S REPORTS R.120/2018 AND R.42/2019, WITH COMMENTS OF THE PUBLIC ACCOUNTS COMMITTEE

Presented to the States on 29th November 2019 by the Public Accounts Committee

STATES GREFFE

2019  R.146

FOREWORD

The  Public  Accounts  Committee  presents  its  Comments  on  the  Governance Arrangements within Health and Community Services ("HCS"), following receipt of the HCS six-monthly update report (attached). This update follows the issue of the Comptroller and Auditor General's ("C&AG") Report: Governance Arrangements for Health and Social Care published 13th September 2018, and her follow-up Report: Community and Social Services for Adults and Older Adults published 4th April 2019.

Comments of the Public Accounts Committee

Background

1. The C&AG's Report on Governance Arrangements for Health and Social Care published in September 2018 found that the governance arrangements in place were inadequate, being overly complex, lacking proper terms of reference and clarity in relation to reporting lines. The C&AG's report on Community and Social Services for Adults and Older Adults published in April 2019 followed on from her 2015 Review of Community and Social Services and expressed disappointment that the lessons of the 2015 report had not been implemented and improvements had not been secured.

C&AG's 2015 Report: Review of Community and Social Services

2. The C&AG's first Report focussed on the many inadequacies of services for older adults, adults and children. It found that the Department faced significant challenges across the range of services it provided. While management had taken significant steps to start to tackle particular issues within Children's Services, the absence of effective arrangements meant that officers could not be confident that similar issues did not affect Adult Services and Older Adult Services. She concluded that there was a risk that issues were masked because of  weak  arrangements,  poor  information  and  a  lack  of  consistency  in management.
3. The report made recommendations in areas such as embedding the right culture, managing risks, making sure managers had the right information, and ensuring effective monitoring and reporting arrangements.

C&AG's 2018 report on Governance Arrangements for Health and Social Care

4. This review considered all Government Departments with responsibilities for health and social care services, including the planning of services based on an assessment of need, funding and delivering those services, and monitoring the effectiveness and quality of services.
5. The C&AG commented that fragmentation of responsibilities reflected silo working. The structures seemed to be based around historic issues, including funding flows, rather than the needs of patients and service users. Responsibility was split between 3 departments with different ministerial accountabilities. There was little evidence of proper oversight to identify future health needs or provide assurance on the current delivery of services. Relationships between the voluntary and private sectors were undermined by bad communication. The

report  also  noted  that  the  Integrated  Governance  Committee  failed  in  its responsibility to oversee an effective clinical and care audit programme, and did not monitor implementation of recommendations.

6. The PAC concurred with the C&AG's conclusion that, notwithstanding the new Target  Operating  Model  would  help  to  simplify  the  existing  governance structures, there  was much  to do to  rationalise, clarify,  communicate and implement  improvement.  Success  would  be  dependent  on  a  strong management-driven  culture  that  promoted  worthwhile  change,  encouraged challenge and embraced learning. The need for clear, documented governance arrangements,  independent  regulation  and  effective  risk  registers  was highlighted in the C&AG's report, along with the need for effective use of complaints  and  whistleblowing  as  tools  of  governance  with  clear  public reporting of performance.
7. The Committee welcomed the Executive response which fully accepted the findings, including that urgent action needed to be taken to ensure that health and social care governance is fit for purpose.

C&AG's Follow-Up report – Adults and Older Adults

8. The 2019 follow-up report by the C&AG identified that lessons learned and improvements made to children's services had not been carried through to drive improvements to other services, such as those provided to adults and older adults. The PAC considers these services to be essential to help some of the most vulnerable people in Jersey. It was therefore disappointed to note that the recommendations from the C&AG's  first report were not acted upon and implemented throughout the department.
9. The C&AG found little action on a range of agreed recommendations, and where action had been taken there was no mechanism in place to measure whether intended outcomes had been achieved. There was a lack of a learning culture, weaknesses in the overarching governance framework, and unmitigated risks associated with reliance on interim staff. Activities taken to manage risk had not been clearly communicated in terms of what the activities sought to achieve.  Sharing  of  information  to  support  joined-up  care  had  not  been achieved,  and  recommendations  to improve  compliance  with  policies  and procedures had not been followed.

PAC Follow-up: Progress Update

10. The PAC acknowledged that the Executive response to the C&AG's follow up Report  stated  that  many  initiatives  were  being  established  by  the  HCS Management Executive and the HCS Board. The PAC was pleased to note that an ambitious programme of change has been embarked upon, and did not want to  disparage  the  efforts  made.  However,  several  proposed  timescales  for completion of projects were marked underway', and the PAC sought more clarity on the  proposed timetables for completed implementation of these initiatives, together with the plans to monitor their success.
11. In October 2019 the Executive provided its first 6-monthly HCS report to the Committee to update it on progress made. The PAC held a Public Hearing with Caroline Landon, Director General of HCS, to question her about that progress

Page - 3

R.146/2019

and, shortly thereafter, received a number of responses to follow-up questions. The PAC was keen to learn how other Government initiatives have impacted on the way in which HCS is run. It asked the Director General to detail the development of quantitative metrics to monitor quality and outcomes, the date for publication of complaint data, and the establishment of clear milestones for the implementation of a governance framework. It also questioned how the HCS will monitor delivery against those milestones.

12. The Director General advised the Committee that a patient tracking list had been established to organise and monitor waiting-lists so that a standard for this would be in place by April 2020. Three Committees had been established to oversee Finance and Modernisation; Risk, Quality and Performance; and People and  Organisational  Development.  The  Jersey  Nursing  Assessment  and Accreditation System has been introduced to assess all in-patient wards and give a rating. Its assessment would include all in-patient areas for the care of adults and older adults. Performance reviews had been introduced and the organisation  was  now  being  clinically  led  through  Care  Groups.  A  new "whistleblowing" policy has been introduced with improvement over the next 6 months being anticipated.
13. The  Director  General  also  referred  to  the  Government-wide  Governance Framework that would enable a database to monitor progress made in the implementation of PAC and C&AG recommendations. Advice on when that database will be fully validated has yet to be provided. HCS referred to the development of its Integrated Performance Report to measure performance, to benchmark against health indicators measured in other jurisdictions, and to provide a framework for improvement across all service lines.
14. The Director General advised the Committee that a Risk Register would be presented to the public board in November 2019 and published in January 2020, but it was likely to be April 2020 before complaints are reported publicly. Recruitment of permanent staff was ongoing, and a workforce plan was being developed to identify gaps and a change in delivery of services through the new Jersey Care Model. The Committee heard that the workforce plan will be ready to share with colleagues by the end of Quarter 1 2020. This would extend to alignment of central information systems  to support the new  Care  Group structures, and include information from a Partnership forum. The Director General informed the Committee that a formal engagement process would involve a further 6 months' work. Efficiencies had been identified in contracts management, maintenance and supply contracts, and in working differently.

Next steps

15. The Committee was pleased to hear of the progress made, but understands there is still a lot of work to be undertaken. It looks forward to receiving a further six- monthly report on further progress achieved, and will hold a public hearing with the Director General in the first quarter of 2020.

Senator S.C. Ferguson

Chairman, Public Accounts Committee

HEALTH AND COMMUNITY SERVICES PAC REPORT

October 2019

1. INTRODUCTION

As part of the One Government approach, the Government of Jersey (GoJ) is modernising services to meet long-term goals for the economy, customers, people, services and island. Like all States departments, Health and Community Services (HCS) has reorganised itself to enable teams to work differently and achieve its ambitions. The changes have involved redefining goals and pertinent to this paper describing and implementing a new governance model these include:

• Strengthening clinical and professional leadership

• Closer focus on safety and quality

• Developing better performance management

• Streamlining governance

Focussing on these goals and external reports published in recent years; a new governance model has emerged which supports the newly formed clinically and professionally led care groups. This has been led from the Chief Nurse and Medical Director's office working across all care groups and departments in HCS.

2. BACKGROUND

The office of the Comptroller and Auditor General (C&AG) published the report, The Office of the Comptroller and Auditor General: Governance Arrangements for Health and Social Care' September 2018 following a review of the adequacy of governance arrangements for existing structures within Health and Social Care (HSSD). This included proposals for changing governance within the then called HSSD and extended to the arrangements put in place relating to health provision outside of the direct control of the States of Jersey such as independent contractors and the private, voluntary and community sectors.

The C&AG report highlighted 22 recommendations of which 14 are directly related to how governance is managed across HCS

In October 2018, HCS (previously HSSD) responded to the C&AG report Governance fit for the future. A Programme of action to strengthen governance arrangements for HCS in the States of Jersey' (October 2018) and emphasised 4 design principles underpinning the proposed governance arrangements which have been incorporated into the new governance framework.

1. Our governance arrangements will provide clear leadership and accountability
2. Our governance arrangements will maintain strong focus on quality and safety
3. Our governance arrangements will help us ensure we make efficient effective use of our limited resources
4. Our arrangements will help us achieve timely, well governed services and service transformation in line with our strategic plans.

In addition, two other documents have informed this report:

1. Recurring Themes: Organisational Culture and Corporate Learning Public Accounts Committee (20 May 2019)
2. A Work programme commissioned by the Chief Nurse specifically looking at assurance for the island wide responsibilities of the Chief Nurse (May 2019)

These documents apprise the scope of a programme of work to devise a governance structure fit for purpose for HCS operating in the context of the States of Jersey Chief Executive's new Target Operating Model (TOM). The new fit for purpose governance framework intends to underpin the delivery of HCS overriding ambition to create a healthy island with safe, high quality, affordable care that is accessible when and where service users need it' as detailed in the departmental operational business plan.

Our aim is to promote an open culture based on good clinical and corporate governance where our services deliver high quality care with an effective quality assurance across our directly provided and commissioned services with clear emphasis on safety and outcomes

3. HEALTH AND COMMUNITY SERVICES CONTEXT

In June 2019, the first public HCS Board was held and this was chaired by the Minister for Health. To support the Board are four assurance committees and in July 2019, the first round of these committees took place, each one is chaired by an Assistant Minister. The Board and Committee structure is demonstrated below in Figure 1.

Figure 1: Health and Community Services Committees serving HCS Board

Figure 2 illustrates the Care Group model that underpins the clinically led and professionally managed organisation that is HCS. Following reorganisation, each Care Group is led by the triumvirate; associate medical director/lead social worker; lead nurse; lead AHP and general manager.

Figure 2: Health and Community Services Care Group Structure

4. FOCUS ON ACCOUNTABILITY

Throughout has been the overarching principle that those running the day to day service (care groups) are accountable to themselves, the organisation, and those it serves; the public. This ensures that the interests of the organisation are balanced and not run for the benefit of those staffing it (HQIP Good Governance Handbook 2014).

The aim is to ensure the Care Group leaders remain accountable and follow a set of overriding principles implicit in clinical governance:

• Deliver safe and effective care based on available evidence and best practice;

• Achieve demonstrable improvements in patient outcomes;

• Increase the involvement of staff, patients, carers and the public

• Provide assurance to patients and the public on systems for safety and quality of care.

The Quality and Safety Care Group ensures our services are delivered to the required professional and quality standards with the required level of oversight and assurance. It was recognised that the Quality and Safety Care Group remit was very broad and there needed to be much more focus if we were to meet the clinical governance reporting arrangements. Part of the revised governance arrangements included the development of a Board Assurance Framework supported by a fully operational risk register. Whilst work had previously been undertaken on risk registers in HCS it was recognised this needed to be built on to ensure there was assurance around the delivery of services within the Care Groups, that any risks, clinical or non-clinical were captured and that the controls were in place to manage risks. This in turn provides assurance to HCS Board and creates the golden thread from the point at which care is delivered, right up to the Board having a clear line of sight.

5. ACTIONS TAKEN IN RESPONSE TO C&AG REPORT 2018 RECOMMENDATIONS

As part of the HCS response to the C&AG report a revised clinical governance framework aligned to the new HCS TOM structure has been developed. The revised clinical governance framework has led to a review of the existing arrangements within and out with the current Quality and Safety team function and wider organisation, to ensure we are in a position to support the Care Groups in the delivery and oversight of their clinical governance activity whilst continuing to develop the Quality and Safety agenda. The decision was made to reconfigure the Quality and Safety team into two parts, both teams remaining under the leadership of the Group Medical Director. This would enable each team more focus set around a specific agenda and would enable the Quality and Safety Care Group to focus on the emerging agenda, whilst being assured that the support for clinical governance was being provided to the Care Groups.

The decision was made to change the function of the existing Quality & Safety Team and to divide it into 2 teams to serve 2 functions; one to focus on strategic quality and safety and the other to focus on operational clinical governance in the care group.

Each Care Group is now supported by a governance facilitator who, whilst corporately managed by a head of governance and risk, works day to day with the care group. This supports the delivery of good governance, the management of risk and accountability within each care group.

To this end the focus for the work has been split into two main components as below: Quality and Safety Care Group main functions and responsibilities:

• Quality and Safety strategy

• SJR

• Inquests

• Serious incident management

• Duty of Candour

• M+M meetings

• Clinical Audit programme

• Clinical Audit days

• Litigations and claims

• GDPR/DP

• Caldicott

Risk and Governance Team main functions and responsibilities:

• Providing assurance

• Supporting the care group leads in delivery of Clinical governance information

• Management of the risk register

• Datix reporting

• Complaints

• CAS Alerts

• Policies and procedures

• KPI reporting

• Interpreter Service

This report details the changes and early impact of these changes in HCS. The purpose of this is to provide assurance that HCS has a workable clinical governance framework from which it can mature as the clinically and professionally led organisation emerges. The aim is also to demonstrate that by identification and management of clinical risk and accountability, available resources are being directed to benefit the islanders.

HCS has committed to avoiding any further review on governance (Recommendation 4) after accepting the recommendations from the C&AG. This report does not form a further review, but details actions that have been taken to implement systems and processes around the new operating model in HCS in order to govern health and social care provision. For ease of reference this report is divided into:

1. A matrix summarising actions taken that cross references recommendations for the CAG & PAC reports.
2. The changes made to governance within HCS to facilitate a more focussed approach within the Care Group structure
3. Embedded documents detailing the material used to implement/operationalise the recommendations which are evidence of the changes made.

During this programme of work further governance issues have emerged and a number have required immediate attention resulting in additional workstreams in conjunction and under the authority of the chief nurse detailed in the work plan. This includes review of how HCS manages policies and procedures going forward including those out of date and an update of the Governance Handbook first written in HCS' response, to Governance fit for the future. A Programme of action to strengthen governance arrangements for HCS in the States of Jersey' (October 2018).

Furthermore, the Director General, Interim Governance Support/Senior nurse (author) and Board Secretary have already met with the C&AG (July 2019) to report on the changes to the HCS governance framework; the counsel and support of the C&AG has been gratefully received.

6. REVIEW OF ACTIONS IN TRACKING AND HOW THE BOARD IS UPDATED

Recommendations from these and all external reports are monitored through a documented process held by the Board Secretary and reviewed quarterly at the Quality & Performance/ Risk Committee under a paper entitled Comptroller and Auditor General Reports Recommendations Tracker'.

For the purposes of this report evidence on actions and implementation of recommendations is attached for evidence. Moving forward it is recommended HCS re-evaluates in 6 months' time to check actions implemented continue to embed and a suggestion is to use scrutiny from Internal Audit's work plan to review evidence.

7. MAPPING C&AG RECOMMENDATIONS TO ACTIONS

The matrix details the recommendation from the C&AG report, actions taken and evidence provided to reassure PAC that the points raised by the C&AG have been addressed.

8. CONCLUSION

In conclusion this now demonstrates of how HCS manages and maintains accountability through the care groups. The C&AG report has provided the opportunity to

develop processes for clinical governance. HCS can now demonstrate the use of a fit for purpose functioning risk register and robust governance from Board to Ward .

The development of a commissioning framework will support further development of robust governance in services commissioned' by HCS. In the meantime, these, and arm's length services have a clear route to Board providing assurance on the quality of services value for money.

9. RECOMMENDATIONS

There are a number of recommendations to further develop the changes made to governance which include: The development of strategies/work streams to support the outputs of HCS:

• Clinical Governance and Risk Strategy

• Quality & Safety Strategy

• Robust Clinical Audit Plan encompassing all national audits

• Patient Experience strategy and development of this work stream to inform the care groups and the Board of how patients view the services HCS provide

• Internal Audit plan (2020) to encompass and test out the changes made to governance to provide assurance to the Board and C&AG

• The development of a Quality Account.