Community and Social Services for Adults and Older Adults - Follow-up (R.42/2019) - Executive response with comments of the Public Accounts Committee [R.42-2019 Res.]

STATES OF JERSEY

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COMMUNITY AND SOCIAL SERVICES FOR ADULTS AND OLDER ADULTS – FOLLOW-UP (R.42/2019) – EXECUTIVE RESPONSE WITH COMMENTS OF THE

PUBLIC ACCOUNTS COMMITTEE

Presented to the States on 24th June 2019 by the Public Accounts Committee

STATES GREFFE

2019  R.42 Res.

FOREWORD

In  accordance  with  paragraphs 64–66  of  P.56/2018,  the  Code  of  Practice for Engagement between Scrutiny Panels and the Public Accounts Committee' ("PAC") and the Executive' (February 2018), the Public Accounts Committee presents the Executive  Response to the  Comptroller and Auditor General's  ("C&AG") Report entitled  Community and Social Services for Adults and Older Adults – Follow-up (R.42/2019, presented to the States on 4th April 2019). The Executive Response and the following comments made by the PAC also reference the C&AG's original Report entitled  Review  of  Community  and  Social  Services  (R.131/2015,  presented  to  the States on 10th December 2015).

Comments

1. The Public Accounts Committee welcomes the comprehensive response to the C&AG's follow-up report and is pleased to see that the Executive team accepts the C&AG's recommendation in full. However, whilst it is pleased to note the many  initiatives  being  established  by  the  Health  and  Community  Services ("HCS") Management Executive and the HCS Board, it notes that the C&AG's first recommendation in her original 2015 report – Review of Community and Social Services was to not only establish clear milestones for the implementation of a governance framework, but also to monitor delivery against those milestones. It is therefore disappointed to note that there are few mentions of how these initiatives will be monitored by the Executive to measure their success or failure. The response to recommendation 1 of that 2015 report, for example, indicates that the C&AG would receive updates from all Assurance Committees and the HCS Board.' However, the Committee wishes to make clear that it is not its role (nor the C&AG's) to monitor the progress on specific measures taken, rather it is the role of the PAC to scrutinise progress against the C&AG's recommendations.
2. Against  recommendation 2  of  the  C&AG's  2015  report,  to  identify  specific measures to reduce reliance on interim staff', the Committee is pleased to note the long-term plan to develop a social work degree on-Island. It also welcomes the recruitment  initiative  within  mental  health  services  to  support  a  significant reduction in agency nursing staff'. However, the Committee is concerned to note that there is no mention of a timescale to introduce similar initiatives to other areas of the services (such as residential care-workers), and little suggestion of how these initiatives will be monitored by the Executive to measure their success or failure.  The  establishment  of  a  People  and  Organisational  Development Committee' is a positive step, and the Committee would welcome more specific information  about  its  role  in  addressing  staffing  levels  throughout  the Government's community and social services.
3. The C&AG's third recommendation in her earlier report emphasises the need for measures to evaluate the effectiveness of steps taken to improve engagement with staff.  Although  the  Committee  welcomes  the  work  undertaken  to  establish clinical and professionally led care groups to drive workforce engagement', the Committee would expect to see evidence of a range of measures put in place to measure the success or failure of this and other initiatives. For example soft' measures such as exit interviews, staff attitude surveys, and hard' data such as staff turnover, staff sickness and performance levels could be used.

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R.42/2019 Res.

4. The Committee is unclear about the Executive's response to recommendation 7, in respect of the need to develop performance standards for all Community and Social Services. In its response, the Executive states that it is developing a revised performance framework, to be in place by Quarter 3 of 2019; however, it also states that a suite of performance indicators' has been deployed for Safeguarding Adults and is reported to the Safeguarding Board. The Committee would welcome clarity on how the performance indicators already established would be developed to  better  understand  performance,  drive  action,  and  enhance  governance throughout the rest of the services.
5. The  Committee  welcomes  the  Executive  Response  in  relation  to  the  first recommendation of the C&AG's follow-up report of April 2019. In it, the HCS Management team has committed to updating the central Government Executive branch on its progress in implementing the recommendations. It also welcomes its commitment to providing 6-monthly progress reports to the PAC. However, it notes that the Executive considers the first of those to be the scheduled PAC public hearing with the HCS Director General on 21st October. The PAC would of course want a written progress report at least 2 weeks before that date, in order to be able to formulate meaningful questions to the Director-General at the hearing.
6. Although the Committee realises an ambitious programme of change has been embarked  upon,  and  does  not  want  to  disparage  the  efforts  made,  it  would welcome more clarity on the proposed timetables for completed implementation of these initiatives, together with the plans to monitor their success. Several proposed timescales for completion of projects are marked underway', and the Committee wish  to  see tighter completion  dates  embedded  in the  plans.  The  Committee wishes to emphasise that the urgency to implement and monitor the initiatives' success is to benefit the Public and improve their health outcomes.

The PAC will be holding hearings with relevant senior officers in due course.

Senator S.C. Ferguson

Chairman, Public Accounts Committee

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R.42/2019 Res.

Health and Community Services response to Comptroller and Auditor General follow-up report on Community & Social Services for Adults and Older Adults

June 2019

Contents

1. Introduction & Strategic Context .......................................................................... 3
2. Findings in the report .................................................................................. ..6

1. What the C&AG review set out to do ............................................................. 6
2. What the review found .................................................................................. 7

3. Actions undertaken to address the findings ......................................................... 8

1. Improved governance arrangements ............................................................ 8
2. Implementing Operational Change.............................................................. 11
3. Performance and management data ........................................................... 13

4. Conclusion ......................................................................................................... 14

Appendix 1 - Response to C&SS C&AG report ........................................................ 15

1. Introduction

This report seeks to address the concerns raised by the Comptroller and Auditor General (C&AG) in her report entitled Community and Social Services for Adults and Older Adults – follow-up' that was published on 4th April 2019.

The Health and Community Services (HCS) department (formerly known as HSSD) fully accepts the C&AG's findings. However, this report seeks to outline the fundamental reform that is currently underway across HCS that goes some way to addressing the issues raised in the C&AG report.

The timing of this follow-up report coincides with the implementation of the recommendations from the response to the Governance Arrangements for Health and Social Care' report that HCS published in October 2018. As outlined in that response, HCS are currently undertaking fundamental changes in our approach to governance' which includes establishing a streamlined board and supporting committee structure'. Alongside the governance work, substantial changes are being implemented within health and social care' as part of the One Government reform.

This report outlines the progress that has been made as part of this reform as well as addressing each of the recommendations in Appendix 1 of this document.

1. Strategic Context

The report findings highlight significant concerns in relation to the services provided to some of the Island's most vulnerable individuals across community, social care and mental  health  services.  The  collective  findings  also  highlight  the  inequity  between physical, mental health, community and social care services.

These findings are consistent with many health and care jurisdictions, and, further support the Case for Change' for the Department of Health and Community Services to ensure there is greater focus on health and care outside of the General Hospital remit.

The newly established Executive team for the department are working at pace to address the issues outlined by the C&AG. There are key 3 strategic initiatives that relate to the report;

• The development and implementation of the Government Plan, Common Strategic Policy 2; Improve Islander's well-being and mental and physical health.
• The Implementation of the ONEHCS vision through the new Target Operating Model for the department. This ambition clearly sets out the objective to fully integrate Health & Community services, ensuring that there is parity between functions and continuity in care for our Islanders.
• Developing the Future Care model, which sees a greater focus on care closer to home, targeted at the most vulnerable groups within the Island.

2. The Government Plan

In HCS, we deliver services that touch the lives of all Islanders and many of our visitors. Our work directly contributes to improving the island's quality of life, the fairness and balance of our society, and the health of our economy. Recognising the importance of our services, we have a very clear ambition for the department:

Our ambition for Health and Community Services is to create

a healthy island with safe, high-quality, affordable care that is accessible when and where our service users need it.

Our ambition is fully aligned to the Council of Minister's Common Strategic Policy, in which improving Islanders' wellbeing and mental and physical health is one of their five strategic priorities. Our ambition also builds on the long-term strategic direction set out in the 2012 white paper Health and Social Services: A New Way Forward' (often referred to as P82) and supports the Future Jersey health and wellbeing vision that Islanders enjoy long, healthy, active lives.

Developing improved Mental Health, Community and Social services across the Island is a key focus of the Government Plan.

3. ONEHCS – Target Operating Model

In order to deliver the changes required within community, mental health and social care services a significant change in organisational focus is required. Over 2/3rd's of the current HCS budget is spent on Acute Hospital based services. It is imperative that HCS commences a robust plan to shift settings and resources of care from the Acute system into the Community. The new Target Operating Model takes HCS further towards this objective with both Social Care, Community and Mental Health services seeing the largest area of investment in terms of Senior Leadership.  

The TOM will implement a Social Care and Mental Health Care group structure that will drive the integrated care objectives for HCS, working alongside the Acute Hospital care Groups.

The Executive team who also have collective responsibility for all of the care groups will lead this structure.

This is a significant change to the previous leadership arrangements whereby CSSD had been led separately to the Acute Hospital system.

4. Future Care Model

Moving forward it is imperative for the department of health to re-balance focus and attention to health and care delivery across the entirety of the care sector on the Island.

The Executive team have concluded that the length of time and intensity of focus for the Future Hospital has further distracted attention from other key strategic priorities such as the development of Out of Hospital Care. Evidence from patient activity across the system suggests the most pressing issues facing HCS relate to the ageing demographic of the Island and complexity of future care needs this presents. It is therefore essential that the Future Care model reflects the care needs of the Island and these growing pressures.

Our Future Care Model has clear ambition to;

• Shift care out of the acute hospital sector into the community as part of a Care Closer to Home model.
• The model of care will be independence focussed with a heavy emphasis on enablement. Shaping the care market to meet this model will be a key objective.
• Prevention of ill-health and dependency is a core objective and this is driving the prominence of the Social Care, Mental Health and Primary, Prevention and Intermediate  Care  groups. These  groups will  lead  the future model  of  care development and implementation.
• Integration of care across all care groups is needed. Evidence suggests our most vulnerable  patient  groups are  accessing  multiple  services  and  seeing  many different practitioners over extended periods of time. The Future Care model must ensure there is continuity in care and improved risk stratification for patients at risk of increasing care reliance.

Our Future Care Model will provide greater focus on patients & clients with escalating care needs.

In addition, the commissioning function of HCS will also shape the wider care market to support this objective.

2. Findings in the report

1. What the C&AG review set out to do

In 2015, the C&AG undertook a review of Community and Social Services operated by the (then) Health and Social Services Department (HSSD). At that time, the Community and Social Services Division (C&SSD) of HSSD provided a range of health and social care services to three groups:

• Children;
• Adults; and
• Older adults.

The C&AG report assessed the extent to which HSSD:

• specified what is required from C&SSD services in line with its overall strategic objectives and monitored the achievement of those objectives;
• analysed existing provision and identified options for change;
• chose between in-house and external provision;
• managed and monitored delivery;
• starting with children's services, had appropriately diagnosed the problems and identified what needs to change with services;
• identified the barriers to change and evaluated their significance;
• where barriers had been recognised, identified appropriate levers for change' and made appropriate plans for implementation; and
• where plans for overcoming barriers had been identified, implemented or was on

course to implement those plans.

In 2019, the C&AG has produced a follow-up report that focuses on the implementation of the recommendations. The follow-up report is focused around three key areas:

1. Arrangements established to manage and monitor the implementation of agreed recommendations;
2. Progress made in implementing agreed recommendations and the extent to which the improvement areas have been addressed; and
3. Adequacy of plans for any outstanding recommendations.

Since the report was published in 2015, Children's Services have moved to the newly formed Department for Children, Education, Young People and Skills (CYPES) as a result of the new Target Operating Model introduced in the second half of 2018. Therefore, the C&AG follow-up report focuses on Adult services and older adult services only.

It is important to note that HCS & CYPES will continue to work together to address the recommendations from CAG in relation to children's health and care.

2. What the review found

The C&AGs findings were structured around five areas:

1. Overall management arrangements

• Community Services governance arrangements remain inadequate;
• No workforce strategy is in place and there is still a reliance on interim staff; and
• A staff engagement strategy has not been developed.

2. Risk assessment processes

• Progress has been made against the recommendation to implement effective arrangements for reporting, evaluating, escalating and responding to risks;
• Health and Safety risks remain; and
• There needs to be better processes in place for monitoring and challenging risks, performance and progress.

3. Information and communication

• There needs to be better information sharing across systems to promote joined up care;
• Performance information should be better utilised including use of KPIs and dashboards;
• There needs to be increased focus on setting service standards and identifying relevant data to inform decision-making;
• Need for clearer governance roles and responsibilities; and
• A process needs to be established to monitor access to policies as well as compliance monitoring.

4. Implementation

• Improved implementation, recording and monitoring of annual appraisals and training needs assessments; and Rollout the Practice Workbook across the service.

5. Monitoring activities

• An effective audit framework needs to be established; and
• A structured approach to monitoring implementation of actions that arise from reviews, accreditation of complaints still needs to be established.

In addition to the CAG findings, subsequent reviews have also been undertaken regarding community, mental health and social care services. Monitoring of Improvement Plans for these reviews is also ongoing and will be shared with the CAG. These include;

• An Improvement Plan following a review of Adult Social Care and Learning Disability services (2018) commissioned by the Safeguarding Partnership Board with a focus on vulnerable persons.
• An Improvement Plan following the Health & Social Care Scrutiny report on Mental Health (May 2019).

3. Actions undertaken to address the findings

As outlined earlier, the timing of this follow-up report coincides with the implementation of the recommendations from the response to the Governance Arrangements for Health and Social Care' report that Health and Community Services (HCS) published in October 2018. As outlined in that response, HCS are currently undertaking fundamental changes in our approach to governance' which includes establishing a streamlined board and supporting committee structure'. Alongside the governance work, substantial changes are being implemented within health and social care' as part of the One Government reform.

We feel that this response therefore needs to reconcile the recommendations from this C&SS report with our over-arching C&AG response published in October 2018 where implementation of the recommendations is already underway. That response outlines the significant amount of change currently being implemented across the department and across the whole organisation.

As the C&AG acknowledges in her report, HCS have developed a number of well specified  work  streams  which  are  relevant  to  delivering  the  outstanding recommendations from her 2015 review. The points that follow outline a number of work streams that are currently underway across HCS that seek to bring about fundamental reform and will go a significant way to addressing many of the issues raised by the C&AG.

1. Improved governance arrangements

Following publication of the C&AG report Governance Arrangements: Health and Social Care' in September 2018, HCS proposed to change its governance arrangements in October 2018. The report found that the department could be clearer about how it runs itself and its processes for governing itself required improvement.

In the months that followed, significant work has been undertaken by the Management Executive team to develop and refine those proposals further, to ensure that they align with the One HCS: Playing our part within One Government' target operating model (TOM). Furthermore, the new HCS Director General has now commenced in post and has provided substantial input into the plans.

During this period of refinement, the HCS Management Executive team has explored potential adjustments to the proposed governance structure. This has resulted in some adjustment to the original proposals in order to better align with the HCS TOM and the Jersey Care Model that has been further developed since the response was published. The refined structure separates leadership/decision making and assurance functions so that the purpose of each group is as clear as possible:

To strengthen the revised governance framework and improve the approach to risk across HCS, a Board Assurance Framework (BAF) is being implemented and used as a reporting tool for the HCS Board to assure itself using available evidence that HCS is delivering its strategic objectives.

It will be used to focus the HCS Board on controlling the key risks that threaten the delivery of these objectives, through the use of a number of assurances and controls. It will be a living document and will be reviewed by the HCS Board, The HCS Management Executive and its assurance committees on a regular basis. HCS have commissioned further support to ensure the delivery of the revised Governance Framework across the department. This approach will ensure connectivity of care delivery between the Care Groups and the HCS Board.

In addition, the Management Executive Committee will be constituted with Clinical and Professional leadership. For Community, Mental Health and Social Care this will include the Chief Social Worker, Associate Medical Director and Head of Mental Health Care Group and a Head of Commissioning.

The Executive Tri-Umvirate (Chief Nurse, Group Managing Director and Group Medical Director) will maintain overall Executive responsibility for the newly constituted care groups.

The C&AG has been kept informed of progress on implementation of the revised governance structure as it has evolved. The first HCS Board is scheduled to take place in July 2019 at which time the Assurance Committee structure will also be established.

2. Implementing Operational Change

Under the new One Government TOM, HCS retains most of the functions of the previous Health and Social Services Department, but will place a greater emphasis on community care for vulnerable groups in order to improve patient experience and deliver more effective joined-up care. The ambition for HCS, as set out in the One HCS proposals published in December 2018, is to "create a healthy island with safe, high-quality, affordable care that is accessible when and where our service users need it".

This is in line with the One Government principles and the Common Strategic Policy. In order to accomplish this, it involves implementing a revised care model (as set out in the figure below) that aims to improve customer experience and health and care outcomes for our service users, their families and carers by joining up high-quality care and making it easier to access that care.

Our One HCS operating model proposals seek to reform the Department's internal management structures in line with the care model, aligning our organisational structures around the following groups:

As part of the new TOM, C&SS is integrated as part of One HCS'. The roles and responsibilities of the new HCS senior leadership team also reflect this change with a wider remit of responsibility covers the whole of HCS.

The new model aims to ensure consistency across all of our care groups, which includes the services that were part of the former C&SS department. Implementation of the new HCS TOM will also seek to address many of the concerns raised in this C&AG follow-up report.

The revised One HCS proposals were consulted upon with staff and partners who were asked for their views on the proposals, including the ambition, the proposed care model and the care groups. There was a significant amount of engagement and the HCS Management Executive team considered the feedback received in great detail, further refining the proposals as a result.

The proposed care model organisational structures and the policies and principles that underpinned them were generally well received during the consultation. There was broad support for the goals underpinning the new organisational design, especially with regard to:

• increased service user involvement in the design of services;
• commitment to strengthening clinical and professional leadership so that more responsibility and increased accountability in decision making can be devolved to front line staff;
• better care co-ordination and integration across HCS;
• a clearer focus on safety and quality for all users;
• stronger performance management; and
• streamlined governance and more visible lines of accountable reporting in a leaner structure.

The HCS Management Executive team believe that, by significantly strengthening and streamlining our governance arrangements and implementing the new TOM, we will go a significant way to addressing a number of the fundamental issues that the C&AG raises. These improvements will ensure that there is regular assurance across all of our services, particularly in relation to management of budgets, quality, risk, resources and performance.

With the assurance committees in place, they will review and scrutinise the activities of HCS and its commissioned partners by using information and data to identify opportunities and weaknesses with HCS leadership then able to implement an informed course of action based upon recommendations of the assurance committees.

To support this, the care groups will be asked to regularly provide metrics or evidence that they are meeting agreed standards. This evidence will be activity or outcomes data, patient feedback or other internal or external reviews. This will enable the committees to establish a framework of sources of information, or controls, to ensure that the department is operating well across all areas.

3. Performance and management data

In relation to performance and management data, a significant amount of work has been undertaken during the last quarter of 2018 and the first quarter of 2019 to develop the Integrated Resources & Performance Report (IRPR) to better understand performance, drive action and enhance governance and assurance of delivery. The IRPR has been in existence for some time and is produced on a monthly basis to monitor key clinical quality and patient safety indicators, local target performance, and financial performance.

Before further development work to enhance the report, the previous version of the IRPR reported on a series of metrics in a factual manner, referencing variation largely against historical achievement rather than any designed plan. It has been recognised that there needs to be more reference to why a metric is being monitored, its interdependencies or impact on the organisation\patients or its importance in achieving corporate goals.

The revised IRPR will therefore seek to:

• Monitor delivery compared to strategic and operational plans with Key performance indicators (KPIs) that assure a safe and high quality service across all care groups.
• Provide drill down analysis to support clarity of root cause.
• Support accountability and ownership of performance from the bed side to the board room.
• Clearly identify impact on delivering the organisational goals and identify interdependencies between metrics and operational delivery.
• Provide intelligence as to the cause of variation so that focused action plans can be developed and implemented. Business intelligence should be driven by the department managing the area being monitored who, in most cases, will also be the owners of any action to be taken.
• Extrapolate forecast outturn performance based on performance to date before and after additional actions.
• Identify current and future risk as a result of performance to date and any unmitigated risk anticipated after action plans have been implemented.

The revised IRPR can now be used in a more proactive way as a tool to monitor performance in a consistent and regular manner, with the care groups having clearer accountability and taking responsibility for the data and the resulting actions that emerge wherever improvement is required.

4. Health and safety

HCS is taking forward the recommendations outlined in this report as part of the Improvement Plan for Mental Health Services. The Minister for Health and Community services has given full support and commitment for plans to improve the Mental Health estate across the Island.

HCS have deliberately prioritised plans and consistently taken positive steps to mitigate our most serious risks. In recognition of the need to establish a consistent and thorough approach to health and safety across HCS, a Health and Safety Committee has been established and had its first meeting in October 2018. It has been put in place to identify and resolve health and safety matters in support of a planned occupational health and safety system, advising on, and making recommendations to the HCS MEx with respect to policies, plans, objectives, reviews etc., and to monitor their effectiveness.

The approach will link in with the corporate structure and government-wide approach to health and safety that seeks to achieve much better performance across the organisation.

Alongside this, the HCS Health and Safety Manager has been regularly reporting to the MEx regarding the most significant and immediate health and safety risks, as well as advising on implications, options and actions required via the health and safety risk register.

4. Conclusion

This follow-up report has given us the opportunity to provide an update on the work that has been progressing since October 2018 and demonstrates that we are regularly taking stock both of the progress made and the results being achieved.

The significant changes outlined in this report will fundamentally transform the way the department manages governance, performance, data and risk as well as the way we interact not only across Adult and Older Adult services, but across the whole of HCS. This puts us in a much better place to build the foundations needed to continuously improve and marks a step change in our approach to strategy and implementation.

HCS are committed to taking all the steps necessary to improve and strengthen governance arrangements as well as delivering a care model that delivers the right care, in the right place, at the right time.

Inevitably, however, introducing and embedding changes at every level of the organisation will take time. As outlined in the response published in October 2018, implementation of these changes will span years not months.

HCS is committed to ensuring that the action plan outlined in Appendix 1  tracked rigorously and will keep the C&AG and the Public Accounts Committee abreast of improvements and developments, seeking advice or guidance where appropriate.

Appendix 1 - Response to C&SS C&AG report