Extended limits of co-payments for G.P. consultations: young people and pregnant women (P.80/2020) – comments [P.80/2020Com]

STATES OF JERSEY

EXTENDED LIMITS OF CO-PAYMENTS FOR G.P. CONSULTATIONS:

YOUNG PEOPLE AND PREGNANT WOMEN (P.80/2020) – COMMENTS

Presented to the States on 10th July 2020 by the Minister for Health and Social Services

STATES GREFFE

2020  P.80 Com.

COMMENTS

States Members are asked to reject this Proposition as amended.

The Council of Ministers supports the overall aim of reducing the costs of primary care to well-targeted groups.

In the Common Strategic Policy, the Government committed to –

"Actively engage General Practitioners' ("G.P.") and other health professionals in developing and testing new models of health care delivery' and to Improve access for vulnerable people including children and an ageing population to all primary  care  services,  including  dentistry,  and  make  it  easier  and  more affordable to use."

In the Government Plan 2020 there is a commitment to "Deliver new models of primary care including the development of a model to support access to primary care for financially vulnerable individuals."

In  the  Government  Plan  debate,   Deputy  G.P.   Southern  of  St.  Helier brought  an amendment seeking to reduce the cost of G.P. consultations for certain vulnerable groups. In his accompanying report, he suggested that patients would still make a co-payment towards fees and the sum of £10 was suggested. This amendment was lost.

Deputy Southern brought P125/2019 to the Assembly in February this year, intending to bolster the Government Plan commitment. The amended Proposition was adopted by the States on a standing vote. It instructed the Minister for Health and Social Services, in consultation with the Council of Ministers, as appropriate, "to devise a scheme which improves access to primary care by reducing financial barriers for patients who are financially, clinically or socially vulnerable, by –

1. identifying and prioritising which vulnerable groups are most in need of affordable access to primary care;
2. for the groups identified in (a), reducing the patient co-payment from its  current  level,  supporting  the  development  of  multidisciplinary services provided in General Practice, which might include expanded roles for pharmacists, nurses, physiotherapists, mental health workers and community support workers; and
3. identifying the appropriate sources for the funding of such improved services; and to bring a proposition for debate by the Assembly in the third quarter of 2020, in order that such a scheme can be implemented from 1st January 2021."

In the short debate, Deputy Southern stated: This Proposition [as amended] asks the Minister to identify which of these vulnerable groups are most in need, so it is entirely within the remit of the Minister for Health and Social Services to focus where he wants this help to go.' In summary, it was for me to come forward with a scheme.

Under my direction, officers have commenced work on drawing up a scheme and have been in consultation with G.P.s. Progress has been affected by officers being diverted to urgent Covid-19-related activities, but is now resuming at pace. The intention remains to  bring  forward  a scheme, properly  funded,  later  this  year,  with  a start  date  of 1st January 2021.

Arrangements reached with G.P.s in April were as a result of health professionals coming together in an emergency. They were a response to tackle Covid-19. The agreement was always accepted as being short term and not suitable as a basis for an agreement outside of an emergency situation. In early July, the Primary Care Body, on behalf of all the G.P. practices on the Island (which operate as private businesses), informed the Government that it would not be renewing the temporary contract and G.P.s would be returning to their practices. Nonetheless, both sides have gained valuable experience and insights from the temporary arrangements and agreed they form a helpful basis for ongoing discussions.

Whilst  Ministers  affirm  their  intention  as  set  out  in  the  Government  Plan,  it  is impractical to take the measures that the Deputy suggests being implemented when the current temporary arrangements expire in less than a month's time. Moreover, at a time when  public  services  have  been  severely  disrupted  by  the  Covid  pandemic  and healthcare needs  to maintain Covid-19 preparedness, attempts to put in place the measures proposed would distract all involved from the important work that needs to be concluded to meet the timetable set out in P.125/2019. Indeed, there is a real fear that the  P.125/2019 work  would  be  superseded  by  the  current  proposals,  resulting  in vulnerable groups (other than children and/or Income Support households) being denied the chance of improved access to primary care. It would also mean a delay or deferral of an important States debate intending to chart a way forward for the improved delivery of care to vulnerable people in this Island.

The Proposition (if adopted) allows no time for the development of new funding methods to address the needs of vulnerable groups. It may mean that it would be necessary  to  fall  back  on  the  present  system  of  paying  rebates  from  the Health Insurance Fund ("HIF"). This seems to be the basis on which the proposer has assessed the financial implications of the Proposition. If the Proposition was to be adopted and funded by the HIF, it may be difficult to withdraw from this type of support in any new arrangement from 1st January 2021. Opportunities for transformation would be lost in supporting the current fee for service model (as opposed to outcomes or performance)  where  G.P.  activity  is  incentivised  without  investment  in multi-disciplinary teams.

Significantly  increased  expenditure  from  the  Health  Insurance  Fund  is  also  not sustainable in the medium to longer term.

The Proposition assumes additional funding of approaching £750,000 can be made available immediately to support the proposals. Government finances are already under severe pressure and this would add an additional burden at a time when our economic future is far from certain.

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P.80/2020 Com.

We know from the work already undertaken to meet the terms of P.125/2019 that a well thought out, sustainable and affordable scheme requires much research and, ultimately, a new contractual agreement for services to be negotiated with G.P.s. The original Proposition envisaged a ten-month period to undertake such work. Here the Deputy is asking us to make such far reaching changes in less than a month.

We have to be mindful that any changes made in haste now would be difficult to revisit in the future. There are a number of vulnerable groups and any changes have to consider them as a whole and not such that one group is prioritised to the detriment of another. It would be wrong to rush ahead now only to regret it later. That is why a considered and coherent approach is required. This cannot be delivered in the next month.

While I recognise that the experience of Covid-19 has been challenging for some Islanders, there are existing measures in place to help alleviate the cost of G.P. visits through Income Support, and new initiatives such as Connect Me are continuing to support Islanders. The co-funding payroll scheme and the CRESS scheme have so far been extended to the end of August to support household incomes. The new Children and Families Hub provides additional support to children, young people and families at this difficult time. This service will continue beyond the Covid-19 emergency as an important element of Government support for children.

The position with regard to our The United Nations Convention on the Rights of the Child ("UNCRC") obligation is likely to be more nuanced than that suggested by the proposer.  Whilst  the  UNCRC  rightly  emphasises  the  rights  of  children  to  access healthcare, my understanding is that it does not prescribe free treatment. There are numerous healthcare models in use around the world which seek to provide this service and nations are able to prioritise services according to the resources available to them. Exactly how Jersey wishes to address its obligation deserves careful consideration and debate rather than a rushed response.

The needs of children and young people remain a key concern and are being addressed within the work that is proceeding as part of the Government Plan and as a result of P.125/2019. This approach has Assembly-wide support and to embark on rushed, short- term, ad hoc, unfunded initiatives for a few months would be unhelpful, underestimating the complexity involved and prejudicing the work currently progressing.

For all the reasons expressed above, I ask Members  to reject this Proposition as amended.

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Statement under Standing Order 37A [Presentation of comment relating to a proposition]

These comments were submitted to the States Greffe after the noon 9th July 2020 deadline as set out in Standing Order 37A due to multiple work commitments by the presenting Department.