Health and Social Services: A New Way Forward.

STATES OF JERSEY

HEALTH AND SOCIAL SERVICES: A NEW WAY FORWARD

Lodged au Greffe on 11th September 2012 by the Council of Ministers

STATES GREFFE

2012   Price code: F  P.82

PROPOSITION

THE STATES are asked to decide whether they are of opinion

1. to approve the redesign of health and social care services in Jersey by 2021 as outlined in Sections 4 and 5 of the Report of the Council of Ministers dated 11th September 2012;
2. to request the Council of Ministers to co-ordinate the necessary steps by all relevant Ministers to bring forward for approval –

1. proposals for the priorities for investment in hospital services and detailed plans for a new hospital (either on a new site or a rebuilt and refurbished hospital on the current site), by the end of 2014;
2. proposals to develop a new model of Primary Care (including General  Medical  Practitioners,  Dentists,  high  street Optometrists and Pharmacists), by the end of 2014;
3. proposals for a sustainable funding mechanism for health and social care, by the end of 2014.

COUNCIL OF MINISTERS

Page - 2

P.82/2012

CONTENTS

1. INTRODUCTION  5
2. THE NEED TO REDESIGN HEALTH AND SOCIAL CARE IN JERSEY  8

– WHY DOING NOTHING' IS NOT AN OPTION

1. AN UNSUSTAINABLE SYSTEM – CURRENT AND FUTURE CHALLENGES 8
2. CURRENT SERVICE PROVISION AND CHALLENGES 16
3. THE IMPLICATIONS OF DOING NOTHING 22

3. OPTIONS FOR THE FUTURE OF HEALTH AND SOCIAL CARE 24

1. HOW THE PLANS WERE DEVELOPED 24
2. THE GREEN PAPER 24
3. GREEN PAPER CONSULTATION 25
4. THE WHITE PAPER 29
5. WHITE PAPER CONSULTATION 31

4. THE PROPOSED NEW WAY FORWARD FOR HEALTH AND SOCIAL CARE 36

1. STRATEGIC VISION PRINCIPLES 36
2. THE NEW WAY FORWARD 37

5. SERVICE WORKSTREAMS 39

1. HEALTHY LIFESTYLES 39
2. REFOCUSING SERVICES FOR CHILDREN 44
3. ADULT MENTAL HEALTH SERVICES 48
4. ADULTS AND OLDER ADULTS SERVICES IN THE COMMUNITY 52
5. SUSTAINING HOSPITAL SERVICES 58
6. CROSS-CUTTING WORKSTREAMS:   62 PRIMARY CARE 62

FUNDING 65 WORKFORCE 69 ESTATES AND FACILITIES 72 TECHNOLOGY 75 DATA AND INFORMATICS 76 COMMISSIONING 77 LEGISLATION AND POLICY 79

6. ROBUST GOVERNANCE 80
7. CONCLUSIONS 84
8. THE NEXT STEPS 85
9. FINANCIAL AND MANPOWER IMPLICATIONS 86

REPORT

A NEW WAY FORWARD FOR HEALTH AND SOCIAL CARE

1. INTRODUCTION

In common with jurisdictions and countries across the world, Jersey faces significant challenges in ensuring the availability of high quality health and social care within a financially affordable sum. We also have some unique challenges, for example workforce pressures, limited services in the community, clinical viability and cost pressures due to diseconomies of scale. All health and social care systems are reforming and changing to meet the challenges of demand, cost and quality. And all systems are spending increasing amounts year on year, on health and social care.

Demographic change will dramatically increase the demand for health and social care. Jersey residents are today living longer than ever before. New medicines, better ways of diagnosing and treating illnesses such as cancer, and other advances have improved life expectancy but mean that many Islanders need to visit the doctor or hospital more often. Chronic conditions such as arthritis and diabetes are rising and patients require treatment and care throughout their lives.

Technological advances are allowing efficiency and quality improvements but are also creating major new costs. Societal change is altering the relationship between services and service users, professionals and the public and between the state and individuals. Increasing regulation in health and social care is increasing quality but also reducing freedom to act outside the norm. And service ethos is shifting from treatment to prevention and promoting independence.

Health and social care services are continually developing in order to improve quality and maintain safety. However, changes will not be able to keep pace with increases in demand due to a combination of significant ongoing funding pressures and the scale of challenges which Jersey faces in the next 10 years. A system- wide view is required, with significant strategic service investment.

Health and Social Services are the largest States Department. We have over 3,000 staff, and an annual budget of £171m. Services are provided over 86 sites. Services directly provided by the Department are:

Jersey General Hospital

Community and rehabilitation services for adults and older adults, at Overdale Hospital plus residential and respite facilities

Long term continuing care' services in States-owned nursing homes (The Limes and Sandybrook)

Mental health services, including inpatient, outpatient, community and Child & Adolescent

Community and Social work for children and families, adults, older adults, learning difficulties; challenging behaviours, disability and sensory impairment, safeguarding and child protection, substance misuse

Public Health, including research, prevention and health promotion

Environmental Health and Health Protection monitoring and regulation

Health and Social services have no direct responsibility for providing health visiting and community nursing. These services are provided by Family Nursing & Home Care, funded in part by the Department.

The Department also has no direct responsibility for either providing or funding Primary Care (GPs, Dentists and high street Pharmacists and Optometrists) – although some limited Primary Care Dentistry for children is provided at the Hospital.

Health and Social Services also holds a number of Service Level Agreements / contracts with third party organisations, to secure services to meet Islanders' needs. These include third sector organisations and off- Island care for specialist requirements.

Health, social care and Third Sector teams need to work closely with one another and with patients, service users and carers to provide evidence-based services, managing demand, promoting health and wellbeing, ensuring equality of access, protecting / safeguarding vulnerable people and enabling people to be cared for in the most appropriate place, living as productive and independent lives as possible. If the States acts now it can:

limit the rate of increase of spend (although realistically expenditure will continue to grow in real terms due to demographic pressure)

begin to reduce the levels of dependency of people such that Islanders are supported to live independently, receiving effective care in lower cost settings

mitigate the effect of increasing demand because of demographic changes

Any change in service will, by necessity, be evolutionary. The timing of changes has been carefully considered in order to ensure that they are achievable, whilst also supporting the required pace. The balance between different elements of the health and social care system has been carefully considered in order to support ongoing service viability, and to support staff in continuing to provide safe, accessible, high quality services.

To enable strategic change, a number of system-wide needs have been considered – including IT support and management capacity to implement change. It is clear that these enablers', along with the changes identified in this report, will be required in order for future services in Jersey to be safe, sustainable and affordable.

The proposals outlined in this Report are the results of almost two years' work. The initial work that informed the Green Paper Caring for each other, Caring for ourselves', published in May 2011, concluded that health and social care in Jersey is not sustainable. The Ministerial Oversight Group note the importance of:

Fully understanding the case for change'; the challenges faced by health and social care services in Jersey and the reason why the current system and model of care is not sustainable

Listening to the views of stakeholders – Islanders, Third Sector organisations and other States Departments

Retaining what works well in Jersey, such as our strong community focus, Parish support and vibrant Third Sector

Designing the health and social care system, and the services within it, in accordance with agreed strategic principles

Identifying sustainable funding mechanisms for health and social care

Addressing the challenges within our estate, most notably the size and condition of Jersey General Hospital – also other estate e.g. mental health and community services

Starting to plan for sustainable Primary Care within the new health and social care system – this being services provided by General Practitioners (GPs), Dentists, high street Optometrists and Pharmacies

Making changes immediately, in order to continue providing safe services into the future

The public consultation on the Green Paper and then the White Paper Caring for each other, Caring for ourselves' demonstrated that Islanders understand the challenges facing health and social care; and that they agree that significant changes are required urgently. Their views, and the views of other stakeholders, have been taken into account throughout the process – and will be incorporated in the detailed planning for service changes.

Only by acting now can Jersey make preparations for a safe, sustainable and affordable health and social care system in the coming years. Countries facing the same challenges as Jersey have already begun to consider this. Strategic investment is urgently required, before the pressures start to impact on the safety of services; we cannot delay any longer.

Service redesign on this scale has never before been proposed by a States of Jersey Department. However, acceptance of it, shown by approval of the detailed proposals laid out in this document, represents a major opportunity for the States Assembly, after considered thought and debate, to work as a group of like-minded individuals, regardless of their own political differences. It offers a unique opportunity to offer Islanders a world class health and social care system for the future, which is accessible, affordable and appropriate, but, above all, safe.

The public consultation has demonstrated that Islanders agree – and are both welcoming and expecting change.

2. THE NEED TO REDESIGN HEALTH AND SOCIAL CARE IN JERSEY – WHY DOINGNOTHING'ISNOTANOPTION

1. AN UNSUSTAINABLE SYSTEM – CURRENT AND FUTURE CHALLENGES

Health and social services are, with some exceptions, relatively comprehensive. Key performance indicators suggest we are performing well compared with similar jurisdictions. Generally, staff are highly motivated and committed, with good levels of experience. Outcomes are good, and Islanders appreciate and value many aspects of their health and social services. However, there are a number of issues with the existing system.

The case for change in summary

The population of Jersey is growing relatively slowly but it is ageing rapidly. Between 2010 and 2040 there will be a 95% increase in the over 65 population, with a 35% increase by 2020. This growth in the older adult population will create a significant increase in demand for health and social care services.

Current  services  are  performing  generally  well  but  they  are  close  to  capacity  and  could  not accommodate this increase in demand. The island will run out of capacity in key service areas over the next five years, but within two years in many areas – and within a year in some areas. The services therefore need significant expansion and/or change to ensure that the needs of the people of Jersey can be met into the future.

Current  services  are  also  vulnerable  due  to  workforce  pressures  with  many  staff  approaching retirement age. Almost 60% of the medical staff are eligible to retire in the next 10 years and, due to changes in medical training and education, these consultants cannot be replaced on a like for like basis. Competition for skilled staff is increasingly hard given, in particular, high costs of living in Jersey and increasingly competitive remuneration packages for similar staff in other countries.

Jersey therefore needs a model of health and social services which can respond to the huge increase in demand while doing so in a way which enables the skills of local staff to be used to the maximum and new roles created which will attract new staff to work in the island.

Decisive action is needed now, in order to secure service changes that meet the island's needs in the short term, and ensure services are safe, sustainable and affordable for the future.

A GLOBAL CHALLENGE

Every health and social care system is experiencing similar challenges:

Demographic change is dramatically increasing demand

Technological advances are enabling efficiency and quality improvements but also creating major new costs

Societal change is altering the relationship between services and service users, professionals and the public and between the state and individuals

Increasing regulation in health and social care is increasing standards and requirements

Service ethos is shifting from treatment to prevention and promoting independence

Health, social care and Third Sector partners and multi-agency teams need to work closely with one another and with patients, service users and carers to provide evidence-based services

Other jurisdictions have invested heavily in health and social care over the past years, in order to alleviate pressures and prepare for the future. The strategies adopted in other countries have been considered when producing the plans contained in the Green Paper, White Paper and this Report.

THE CHALLENGE FOR HEALTH AND SOCIAL CARE IN JERSEY

Demography

The Island's population is ageing rapidly. The numbers of people aged over 65 will rise by 35% between 2010 and 2020, with a projected increase of 75% by 2030 and 95% by 2040:

Figure 1: Projected demographic changes, 2010 - 2040

These changes will place increasing demands on services. Typically an older person (aged 65+) is estimated to use up to four times as much resource as an average adult.

Figure 2: Index of relative health care expenditure by age.[1]

The challenges presented by an ageing population include increases in demand due to:

Increased prevalence of long term conditions such as Chronic Obstructive Pulmonary Disease (COPD, or lung disease), cardiovascular disease, diabetes, back pain and rheumatological diseases

A higher number of individuals surviving into older age following diseases such as cancer – but with additional complications and co-morbidities

Greater demand for musculoskeletal and orthopaedic services both for trauma and emergencies, for example resulting from falls or fractured neck of femur, and for joint replacement e.g. hips and knees

Increased demand for age-related Ophthalmology services such as cataracts and macular degeneration

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.

Health and wellbeing

Over 85%[2] of adults in Jersey rate their health as good or better. There are differences across age groups, with 91% of individuals aged between 16 to 34 rating their health as good or better, compared with 70% of those aged 65 and over. Whilst this suggests that the public in general have a positive perception of their health and wellbeing, it also highlights that the public may be unaware of how their lifestyle choices impact on their health and wellbeing[3]:

Alcohol

Approximately half of men (46%) and more than a third of women (35%) exceed recommended daily levels of alcohol consumption

There are over 250 alcohol-related emergency admissions per year; it is estimated that the hospital spends approximately £2m on alcohol attributable conditions per annum

Approximately 11,000 people would meet the criteria for an intervention to reduce their alcohol consumption

Obesity

1 in 8 adults are obese and 1 in 3 are overweight

1 in 10 5 year olds are obese and 1 in 4 are obese or overweight

Obesity costs the States of Jersey and other employers an estimated figure of almost £4m each year including health-care costs and sickness absence

Smoking

An estimated 170 individuals each year die of smoking related disease

Of approximately 17,000 smokers, 12,000 want to quit

Approximately 400 babies leave maternity care to a home where at least one person smokes

Physical activity

Just over half of the adult population do not achieve the recommended amount of physical activity each week

Older adults are less likely to be participating in physical activity on a regular basis

Young people are less likely to walk or cycle to school than in the past

Mental health and wellbeing

Levels of suicide are higher than England and Wales. Suicide is the biggest cause of premature death

15% of the adult population score themselves with high levels of depression and anxiety - this equates to more than 10,000 people in 2010 rising to more than 11,000 people in 2020.

40% of repeat visits to GPs are by people diagnosed with depression and/or anxiety

Long term conditions

Excessive alcohol consumption, in addition to smoking and/or a poor diet/exercise regime can lead to a higher prevalence of long term conditions such as diabetes, COPD, CHD and dementia[4]

There are over 3,370 patients registered as diabetic and a further 1,563 patients estimated to be unregistered or undiagnosed with the condition[5]

By 2020 12,000 people (>13% of the total population) will have diabetes

An estimated 3.3%[6] of the population aged 16+ (over 2,360 individuals) are diagnosed with COPD

Approximately 15% of smokers will develop COPD[7]

By 2020, COPD will be the third leading cause of death and the fifth leading cause of disability

Cardiovascular disease affects 13% of the population; the prevalence increases with age

An increase in moderate and severe dementia of 38% by 2020 (to 1,716 people), with a 64% increase by 2025 (2,040 people) and a 154% increase by 2040 (3,167people)

A small island

In normal circumstances our population of approximately 100,000 would be considered too small to support comprehensive hospital services and very specialist social care services – this would normally be provided for a population of over 250,000. However, geographical isolation and infrequent but material travel difficulties mean that providing a significant level of hospital services locally is essential, and that it is desirable to provide local care packages for people with complex needs.

Accordingly, the unit cost of delivering health and social services in Jersey is higher compared with systems serving larger populations. This is due to the fixed costs of key services, that are still necessary to support relatively low levels of activity. This, along with the cost of living (including the cost of land and buildings) in Jersey leads to an additional "premium" of approximately 15 – 20%[8].

Workforce

Staffing in health and social care is relatively light and highly reliant on very small numbers of individuals, particularly in medical staffing. This is an issue as many health and social care staff are approaching retirement age; almost 60% of senior medical staff will be eligible for retirement in the next decade. Many of these retiring professionals are generalists who can treat a range of conditions. However, new health professionals are now trained to be specialists, focusing on more narrow, specific areas of care. This means that every retiring hospital doctor may need to be replaced by a number of specialist doctors.

Jersey experiences challenges with attracting and retaining health and social care staff, particularly nurses. This is partly due to high cost of living, competitive pay packages in other countries, some rules for entry and residency and the personal profile of nurses, who are more likely to have families and are usually sole wage earners when they arrive. There are also global shortages in some skills, such as Theatre Practitioners and Neonatal Nurses.

Due to low patient volumes, maintaining specialist skills can be difficult. Roles have not developed in line with international best practice, as there are only a limited number of expanded role practitioners. Non- medical prescribing is only now being developed, and the skill mix needs to change within teams in order to secure service sustainability and offer more attractive career options.

Estate

The buildings from which services are provided are deteriorating and in many cases are cramped and do not meet modern standards. Space allocation on wards is about half of what would now be expected for the number of beds. The configuration of six-bed bays is not consistent with the requirements of infection control and does not promote privacy and dignity for patients.

The hospital has developed over many years, and as a result, some Departments are not ideally located. This can lead to inefficiencies in the way care is delivered, for example due to the distance between areas that should work closely together. The hospital requires complete refurbishment and redesign or rebuild in the next decade, and other facilities e.g. Overdale also require refurbishment and upgrading. Some facilities have deteriorated to a point where they have required closure and complete refurbishment e.g. Clinique Pinel.

Recent years have seen growing interest in the effects of healthcare building design, and the environment more widely, on the wellbeing of patients and staff and this is supported by a growing body of evidence.

The most detailed review of healthcare facility design and specific outcomes in healthcare, examined 500 papers and reports[9]. This identified a range of positive outcomes including reductions in hospital acquired infections, patient falls, medical errors, pain, patient stress, patient depression and length of stay as well as improvements in staff outcomes' expressed in terms of injury and stress.

Payment systems

Where people are treated, as well as by whom, matters. Current funding arrangements do not always encourage people to seek the right help in the right place from the right health and social care professional. The current co-payment for GP services is understood to contribute to high Emergency Department attendances. It was the most frequent topic in the White Paper consultation, and the Jersey Consumer Council has recently undertaken a separate survey of Islanders. The survey is due to report in October 2012. As at 10 September 2012 Jersey Consumer Council had analysed 4,026 questionnaires. Whilst the study was not statistically representative of the entire population because respondents self-selected, an interesting set of themes emerged.

From their preliminary analysis of 4,026 questionnaires, Jersey Consumer Council has noted that:

Approximately 29% of respondents felt that the cost of visiting a GP was Expensive but worth it', 12% felt that the cost was About right', 6% felt that it was So expensive that it stops members of our household from going' and 5% of respondents felt that the cost of visiting a GP represented Good value for money'. Approximately 48% of respondents felt that the cost of visiting a GP is expensive and therefore members of their household only go when they really have to.

Approximately 22% of respondents felt that the cost of visiting a Dentist was So expensive that it stops members of our household from going' and only 4% think that the cost of visiting the Dentist was about right.' Approximately 44% of respondents noted that the cost of visiting the Dentist is expensive and therefore members of their household only go when they have to. Circa 28% responded that Dentist visits are expensive but worth it, and approximately 2% said that Dentists are good value for money  

The majority (52%) of respondents would prefer to continue with the current system of funding. 15% believed in means testing, 11% in reducing general taxation and introducing private health insurance and 7.5% believed that payments should be payroll-based. 15% of respondents reported that they were not sure about the answer to this question.

Excellent experiences of healthcare were reported

There is a perceived lack of clarity over the availability of price lists for services and treatments in GP and Dental practices

Concerns were raised about Optician costs, as glasses and lenses costs are reported by some as being prohibitive for older people and those on low income

Repeat prescriptions and medication for those with long-term health problems should be considered differently, and there should be reduced GP, Dentist and prescription charges for older people

Practice Nurses should be used more for basic procedures e.g. blood tests and vaccinations

Service models and the health and social care system

Individual services are reviewed and developed by the teams providing these services, led by the relevant Clinical and Corporate Directors. However, these service changes are often limited by available funding. The KPMG Technical Document, and Caring for each other, Caring for ourselves all identified challenges with the current system:

Services are not well integrated across States Departments and with external agencies, and there is a high dependence on care provided in the hospital and other buildings (residential homes etc)

Health services are relatively medically dominated, with correspondingly low levels of team-based practice and limited roles for other professions such as nurses

The lack of 24-hour community services means that the system is relatively institutionalised; more care is delivered from buildings (hospital, care homes, residential services for children). It also reduces choice, e.g. at the end of life

The limited range and availability of community services, along with the waiting lists for long term nursing care can cause people to stay in hospital for longer than is medically necessary

Notwithstanding the diseconomies of scale from being a small, somewhat isolated island, medicalised and institutionalised care models are more costly

As noted above, the private sector GP system is believed to contribute to a high use of hospital services. This unintended consequence of co-payment for GP appointments means that some patients access the Emergency Department and Outpatients, rather than their GP. The Jersey Consumer Council's survey on Primary Care has made available its initial report on the impact that the Primary Care funding system has

on the hospital. Of the 4,026 questionnaires analysed, Jersey Consumer Council reported that:

- Nearly 1 in 5 households who responded had used the Emergency Department for a problem that was neither an accident nor an emergency

- 75% of respondents surveyed feel that patients attending the ED with non-urgent health problems should pay a fee

- 65% of respondents feel that ED should charge the same amount as a GP for non-urgent care provided

We are not taking advantage of services and technology which reduce costs and improve care, and enable individuals to be cared for in non-hospital settings

We have a vibrant Third Sector and a strong Parish-based system, but there is a perception from some that the Third Sector requires more support in order to fulfil its potential and be a true partner in delivering care and supporting Islanders.

There are insufficient respite places, particularly for children and people with dementia. This increases the pressure on carers, and can cause individuals to be admitted to costly residential care more quickly

2. CURRENT SERVICE PROVISION AND CHALLENGES Public health (including health promotion)

Health promotion is delivered by the Public Health Directorate. It focuses on the priorities drawn from results of the Jersey Annual Social Survey, together with disease and mortality rates, and includes mental health, alcohol/substance misuse, obesity and smoking.

Current challenges include:

Absence of an integrated strategy for health and wellbeing promotion

Duplication in information and self care material, with no central point where people can access all health promotion information

No quality assurance standards to control/approve the information which is available

Lack of a coordinated response to promote self-help

Lack of a comprehensive picture of population health needs - in particular for specific groups such as children, Portuguese community etc, which will allow targeted service development

Limited ability to monitor the improvement or decline in health and social care outcomes, due to underdeveloped information systems

Lack of coordination and integration between different services working with people who may have a similar underlying issue e.g. alcohol

Primary Care

Primary Care should be the first port of call for a patient, apart from in an emergency. Primary Care comprises:

General Practitioners (GPs) and practice staff

Dentists

Pharmacists

High street Optometrists

At present, patients can choose which GP they would like to see, but have to pay a charge (generally c£35) for seeing them. Dentists and Optometrists also operate on a fee-for-service basis (although Primary Care dentistry for children up to age 12 is available at the hospital).

This model of privately delivered Primary Care alongside other States-provided services has benefits but also creates perverse incentives which skew natural patterns of service usage. There is a high number of GPs (relative to the size of the population) but very low levels of supporting nursing and allied health professional staff in primary and community care settings, and limited integration with social care and Third Sector provision. As a result the skills of GPs are deployed on tasks that, elsewhere, would be delegated safely to other professionals, such as ear syringing and blood pressure monitoring. It also contributes to a higher use of (free) Emergency Department services relative to other jurisdictions, especially for under 5's and people with long term conditions.

Primary Care information systems are variably developed, with a mixture of systems for recording, monitoring and sharing information. The ability to register with more than one practice increases the risk of data duplication and creates governance concerns.

Hospital care

The majority of hospital care is provided free at the point of delivery. Almost 50% of the population has private health insurance but the coverage of insurance policies varies and many people still opt for States- provided care.

Jersey General Hospital provides a comprehensive range of hospital services including emergency care and Emergency Admissions Unit, medical and surgical specialties, anaesthetics, ITU, obstetrics, paediatrics and therapies. Its facilities include:

245 beds in total – 217 public and 28 private

4 main theatres (one is a ring-fenced emergency theatre)

2 day case theatres

2 endoscopy theatres

1 maternity theatre

Some specialist treatments are provided in UK hospitals, where there is insufficient volume of patients in Jersey, or where there is a need for highly specialised personnel and/or equipment.

The key challenges within the hospital are due to workforce, estates and low volumes – all of which have already been outlined in this Report.

There are low numbers of middle grade medical staff, challenges with recruiting and retaining nurses and the nurse to bed ratio (including all nursing staff grades) is lower in Jersey compared with English peers.

Jersey General Hospital's bed occupancy is normally much higher than best practice of 85%, with more than 95% occupancy in some acute areas. This may be due to adoption of a more medicalised model of care, with fewer nurse-led services compared to other organisations. Without service changes, Jersey General Hospital will start to run out of beds by 2017.

The buildings from which services are provided are deteriorating and in many cases are cramped and do not meet modern standards. Departments which would need to work closely together are not always located together, and this can contribute to inefficiency and to fragmented patient care, for example due to the need to travel or transport patients between Departments. The hospital itself requires complete refurbishment and redesign or rebuild in the next decade.

Standards and requirements are increasing year-on-year. This impacts the hospital in terms of training and on insurance payments for medical staff – for example, the insurance quote has increased by £1.5m between 2011 and 2012.

The hospital has invested in a new patient information system, TrakCare, but this is not yet comprehensive. Further development and technical support is needed to build a fully functional electronic patient record system that will support patient care and provide data for audit, reporting outcomes and accreditation and will  link  across service  providers.  Lack  of  consistent  clinical coding  also  hampers  outcome  reporting, benchmarking and strategic planning.

Adult Mental Health

Adult Mental Health Services are predominantly provided by the Adult Services Division of Community & Social Services (Health and Social Services) and by GPs. There are a range of Third Sector organisations providing high quality care, including MIND Jersey, Silkworth Lodge and The Shelter Trust.

The level of service provision available for mild to moderate conditions is low as services are mainly provided within Primary Care and are not universally accessed.

States Departments are working jointly to improve their planning, response and ongoing support to people with complex needs in the community. This includes close liaison between Health and Social Services and the Police, Social Security, Housing and Home Affairs. Further progress is required in order to continuing improving services and to improve the experience for the individual receiving the service, in particular in regards to establishing an appropriate place of safety' other than a police cell.

The main challenge in Jersey is to continue to develop models of care as alternatives to medical and/or institutional models. Over the last ten years there has been significant progress in moving services into the community. This includes:

Specialist community multidisciplinary teams, comprising social work, nursing, occupational therapy, physiotherapy, speech & language therapy, psychology, psychiatry and positive behaviour support services, with specialisms in both mental health and learning disability / autism

A Psychiatric Liaison Service, which achieved accreditation from the Royal College of Psychiatry in recognition of the high standards and quality of work

The Recovery Lounge' at Clairvale Road, which is designed to reduce the need for inpatient admission.

 Key challenges include:

Supporting a range of providers (including Third Sector and Primary Care) to work in partnership with health and social services

establishing more appropriate early intervention, identifying people who are at risk within the community

developing a robust rapid intervention / crisis resolution service

reducing the rate of risk of self harm and/or suicide

Older Adults Mental Health

Dementia services are currently provided by:

Community and Social Services teams

The memory clinic based at the Poplars

The 14 bedded assessment unit

52 continuing nursing care beds

The Jersey Alzheimer's Association, which has an active membership and provides support to carers and tailored activities to people living with dementia

The independent sector, who provide a number of residential beds, and more recently specialised nursing beds specifically for people with dementia.

Challenges include:

Coping with the significant projected increase in moderate and severe dementia (projected to increase by 38% by 2020)

Supporting carers with information, support and respite services

Early identification of people living with dementia

Raising public awareness of dementia

Supporting the Third Sector in developing services

Providing appropriate lifetime housing

Community services (health and social care)

Adults and Older Adults

Community nursing and home care is currently provided by Family Nursing and Home Care (FNHC), with Community & Social Services providing social work for all age groups. FNHC provide District Nurses, Health Visitors and School Nurses, as well as home care assistants. Help at home is currently available to support independent living, and includes home care to support basic needs such as shopping, laundry and meal preparation. However, services are not available 24 hours, and benchmarking indicates that Jersey has a relatively low number of registered community nursing staff.

Currently, care for people with long term conditions is mostly provided by the hospital, by GPs supported by a small number of practice nurses and by FNHC. Support for specific groups of patients with long term conditions is also provided by a range of Third Sector organisations, such as Breathing Space, Diabetes Jersey and the Jersey Heart Support Group. Integration of services, however, is limited.

Emergency hospital admissions are driven by general medical patients and other than the Samares Rehabilitation Ward , there are no intermediate care ("step-up" and "step-down" facilities) in Jersey. These facilities would help to prevent individuals being admitted to hospital ("step-up") or support discharge ("step-down"). Jersey also has no specific model for self-care or telehealth or telecare infrastructure, which can help individuals manage their own condition more effectively.

Limited choice exists for end of life care, other than for cancer and motor neurone disease, where Jersey Hospice Care provides excellent services. As a result of fixed term funding from several charitable organisations one Palliative Care Nurse Specialist has been employed, with a further Liverpool Care Pathway Nurse employed for a period of 1 year in January 2012. In addition, charitable funding has supported the appointment of a Specialist Registrar in Palliative Care, which is shared between the Hospital and Jersey Hospice Care.

As a result of the service availability as outlined above, high use is made of institutional models of care and lower numbers of older adults are living independently in the community. It is estimated that c1,000 older people are cared for in residential settings currently, although this includes private sector as well as States- provided and funded care.

With no changes to the service model, the increasing demand expected with an ageing population will create unsustainable pressure on the hospital and on the whole health and social care system.

Carers

As with all countries, it is difficult to estimate the number of unpaid carers in Jersey. However, the pressure on unpaid carers is immense, and is compounded by the high cost of living, which results in one of the highest proportions of female workforce. The Carers Strategy "Caring for life, a life for Carers" was jointly developed following a workshop in October 2008. It is due for renewal in 2012. Following discussions with Jersey Association of Carers Incorporated we are proposing that this is developed by the Carers Partnership Group.

Children

A range of services for children are currently provided in the Island. These services provide preventive, protective, clinical and emotional support to children and their families across different levels of need and are provided by Health and Social Services and Third Sector providers such as Brighter Futures.

The traditional model of reactive services is no longer appropriate. 20% more children are cared for in residential settings rather than by foster carers, when compared to the UK. Children's services are under pressure because of very high referral rates and the difficulty of securing a good supply of foster carers, and the current institutionalised model had led to increasing and unsustainable demands being placed on Statutory Services, including Residential and Fostering Services. In addition, there are high levels of Emergency Department activity for children which could be more appropriately seen within Primary Care.

At an operational level there is much passion and energy. However, greater coordination is required between the key statutory and voluntary agency partners in order that the right child gets the right intervention at the right time. Joint planning and interagency planning with common goals are vital.

A number of important forums bring together key service providers. For example the Jersey Child Protection Committee, Early Years Childcare Partnership and most recently the Children's Policy Group which has produced the Children and Young Peoples Framework.

There is an absence of published local outcome measures, although anecdotal evidence from colleagues working in the education system note a significant variance in children's school readiness at age five.

Other challenges include:

Low thresholds for referral to Service for Children, as common assessment tools do not exist

Limited capacity for early intervention in universal services

The majority of antenatal care delivered in hospital

High risk of disjointed and duplication of services

Absence of robust health intelligence about children's needs

Third Sector

Jersey has a vibrant Third Sector, providing information, support and services for particular groups of patients, service users and carers. There are almost 300 registered charities in Jersey, with c70 focusing on different aspects of health and social care.

Community support groups exist in some Parishes, e.g. in St Clement. These are run by volunteers, and provide support to enable individuals to live more independently. Despite offering a quality service for a proportion of the population, other parts of the island population are unable to access this support or equivalent creating an inequity across Jersey.

There is limited integration between Third Sector providers, and between Third Sector and States-provided health and social care. This may lead to duplication or gaps in services, and opportunities to work jointly with care designed and delivered for individuals may be lost.

Many Third Sector organisations are keen to engage more fully with health and social care; whether this is to advocate on behalf of their members, to contribute to service planning or to provide health and social care services in the future. However, capacity and capability challenges exist and there is a lack of co-ordination and understanding within the Sector regarding the services offered by each organisation.

Previous Service Level Agreements have been short term and vary in their robustness and in terms of the information produced in order to assess outcomes and value for money. The short term planning cycles compounded this, and have led to some Third Sector organisations feeling unsupported and uncertain about their future.

3. THE IMPLICATIONS OF DOING NOTHING

Continuing to deliver services as they are at present is both  unaffordable and  unsustainable. Due to demographic pressure caused by the elderly population, capacity will start to be exceeded within the next year, but there are severe limitations on increasing capacity due to staffing availability and the pressure on buildings as activity increases.

Older adult services will quickly reach capacity. This will require significant additional funding and facilities, or will to lead to overspill into other care settings e.g. the hospital, causing operations to be cancelled and waiting lists to grow. Increased spot purchasing of independent sector capacity will be required. The current institutionalised' model will continue, which impacts people's ability to live productive and independent lives in the community, supported by a range of care professionals. It also reduces choice and increases pressure on carers.

Pressure on staff will increase significantly as caseloads and workloads increase. This is compounded by the retirement profile, which will lead to increased stress and sickness absence and a further exacerbation of the current vacancy and locum situation – which further increases costs and clinical risk, and impacts quality and safety. As community staff will become more stretched, so the amount of time available for each patient / service user decreases. This has two effects:

The length of stay in hospital will increase as services to support people at home reduce further

An individual's condition can worsen if it is not being well managed. The numbers of Islanders presenting at the Emergency Department and/or requiring unplanned care will increase, and more people will need to be admitted to hospital

The hospital will quickly cease to be sustainable:

As emergency or unplanned admissions increase and lengths of stay increase, hospital beds start to become full

As hospital beds become full, operations will be cancelled more often. Waiting times will increase, and people's health will suffer as their condition worsens whilst they are waiting for surgery

A model based predominantly on emergency and unplanned care will reduce the attractiveness of a career in health and social services in Jersey. Skilled and experienced staff will start to leave the Island, and it will be even more difficult to recruit replacements. Eventually, some services will become unsustainable because there will not be enough staff to run them

The wrong balance of planned and unplanned services will mean that some services may have to close because volumes may fall below safe levels (because staff are focusing on unplanned care and so do not have the capacity to provide planned care as well). Jersey residents will then have to travel abroad to receive services

Closing services may mean that emergencies have to be stabilised and flown off island – subject to flight availability – instead of being treated in our general hospital

With this scenario, the hospital will eventually cease to be a hospital as we currently know it and will become a "stabilise and send off island" emergency centre with some simple day surgery, outpatients and diagnostics services only.

If Primary Care continues to be delivered by a medically-led model, the opportunity to enhance and expand the Primary Care team will be lost, with co-payments continuing to deter some patients from accessing their GP or Dentist, health inequalities will increase as patients remain undiagnosed/untreated, and/or the pressure on unplanned care will increase as they continue to present at the Emergency Department.

Access to Dentistry and Optometry, particularly for those on low incomes, will be severely limited, and Pharmacists may be under-utilised in terms of their skills and range of services.

Significant opportunities for improving the health and wellbeing of the population are also lost as self care remains underdeveloped, leading to increased demand and cost in later years. Conflicting information and duplication in resources will continue to exist. Pockets of good practice will continue, but Third Sector and other organisations will soon become swamped by the increasing elderly population with long term conditions.

Public health intelligence will continue to remain a challenge, and undertaking robust health needs assessment of the population will be severely limited. As a result, the health and social care needs of the population may not be accurately assessed, and the most effective and appropriate care provided.

The challenges relating to services for children will continue; more children will be in residential care rather than with foster carers and families. Social, behavioural and psychological issues will continue into later life and may prevent children from becoming active members of society and becoming good parents themselves.

Stigma for mental health will continue, and more individuals with low level mental health issues will be untreated. This will lead to an increase in sickness and absence and incapacity claims due to mental health issues, and will impact not only on health and social care, but also on economic productivity, social security payments and on families and society as a whole.

3. OPTIONS FORTHEFUTUREOFHEALTHANDSOCIALCARE

1. HOW THE PLANS WERE DEVELOPED

Health and Social Services embarked on its review of health and social care in Jersey in late 2010. The aim was to:

Clearly identify the challenges, both current and future, through analysis, benchmarking and engagement

Identify international best practice and consider how these could be applied in Jersey

Plan, design and deliver a set of scenarios for consultation, through engaging with political, clinical, professional  and  managerial  leaders from  across  the  health  and  social  care system  and  stakeholder representatives from key Third Sector partners

KPMG, who were working with Health and Social Services at that time, concluded that health and social care in Jersey is not sustainable. The challenges pertaining to the current system and potential care models were identified in their Technical Document.

2. THE GREEN PAPER

The Ministerial Oversight Group and Steering Group agreed three scenarios for consultation in the Green Paper. These were developed as a result of analysis, benchmarking, stakeholder interviews and discussions, reviewing best practice and workshops:

3. GREEN PAPER CONSULTATION

Public consultation on the Green Paper Caring for each other, Caring for ourselves' took place between May and August 2011. Consultation activities were designed to reach a range and broad spread of:

Age groups

Parishes

Staff

Vulnerable and hard to reach groups

Interest groups

Service providers / partners

Activities included public meetings, focus groups with schools and high profile media coverage. Staff drop- in' sessions were held from 7am to 9pm on three days, in order to be accessible to night staff as well as those working during normal office hours. Focus groups were also held with Islanders with sensory impairment, in order to consider their specific views regarding access and equality.

More than 1,300 Islanders responded to the consultation. The response was overwhelmingly (86%) in favour of redesigning health and social services so that they continue to be safe and affordable for the future, and many respondents included detailed comments and viewpoints.

Responses were received from across all age groups. 69% of responses were received from individuals; 17% from organisations, such as Family Nursing and Home Care, dDeaf Awareness Group and MIND Jersey. More women than men responded.

It should be noted that the Green Paper and White Paper consultations do not provide a demographically robust sample of public opinion. People chose to take part of their own free will and therefore, the views expressed cannot be taken as representative of the views of Islanders or all organisations as a whole. However, every effort was made to engage with as wide a range of people as possible through the various mechanisms to try and capture the diversity of Islanders' views.

Figure 3: Age profile of respondents to the Green Paper

RESPONSES

Values about health and social care

The overwhelming message from the Green Paper consultation was the positive views of Islanders about their health and social services. The results of the survey show that the majority of the respondents believe it is very (81%) or fairly important (16%) to continue providing a wide range of health and social care services on island.

The majority find it very important (82%) or fairly important (16%) that in future these services are free, or affordable, and available to all.

Several respondents added comments relating to valuing health and social services. Some say that good health and social services are one of the main duties of the States of Jersey, that health and education should take priority over other budgetary demands and that if cuts need to be taken from elsewhere to pay for this then this should happen.

Should we change services in Jersey and, if so, how?

86% of respondents agreed with Scenario 3 (a new model of health and social care). The consultation concluded that:

To be fit for the future challenges the island faces, the health and social care system needs to change. Responses indicated that the way we provide health and social services now is not sustainable or affordable in the long term, and "doing nothing is not an option".

There is an understanding that simply raising revenue or controlling spending will not address the issues.

While the majority of people expressed these thoughts, there were some who believe that services should continue as they are, or should be reduced so that we live within the current budget for the next 30 years. However, very few Islanders expressed a view that the system could not be improved.

What is important?

The vast majority of respondents (90%) agreed that "The States should ensure that preventing ill health is as important as curing ill health". Some people felt that a large benefit could be gained from this area in the long term, whilst others were not sure whether this would be possible.

Islanders indicated that mental health is just as important as physical health. They also agreed that disadvantaged children and younger people should have better access to health and social care services.

What is the individual's role in their own health?

There were mixed views on having "responsibility for your own health". In particular, there were concerns about "self-inflicted" injuries or illnesses. Some people argued that it was not always possible for everyone to look after themselves and that vulnerable, ill or disabled individuals should not be disadvantaged.

Where should care be delivered?

Most respondents agreed that "People should be able to live in their own home for as long as possible, providing they have the right health and social care support from the States of Jersey, the Third Sector and Parishes".

The vast majority of people (90%) agreed that "Instead of going to a hospital doctor or GP, I would be happy to be seen by a nurse, a pharmacist or other care professional, for appropriate minor procedures such as measuring blood pressure or monitoring my diabetes."

Most Islanders said they would welcome qualified nurses working with GPs to free up their time, but others were not in favour of nurses doing what they considered to be the work of a GP. Some people commented that the GP system in Jersey was already very efficient and they were concerned about damaging patient-GP relations, and others were concerned about the cost of visiting a GP.

Respondents also indicated that off-island travel was acceptable for some treatments. Some Islanders would rather not have off-island treatment, whilst others felt that going away for care to be inevitable on a small island like Jersey. Respondents also expressed views on whether patients should travel off island to see a doctor, or whether doctors should visit Jersey to treat patients.

Professionals working together to deliver better integrated care was important, and some people noted that Jersey's charities should receive more funding and support.

Paying for health and social care

The vast majority of respondents thought that health and social care should be accessible and affordable, if not free, to all. However, there was a range of views about who should fund this care, and how.

Fairness – who should pay?

The need for affordable care was often stressed, and many people felt payment and funding needed to be explored in more depth.

Most Islanders said that those who cannot pay should still enjoy high quality health and social care. Opinion was then split about whether the amount of free care available for each person should be capped, with some respondents expressing concern about the costs of care for people with long term illnesses.

Some Islanders commented that if health and social care was capped, for some conditions or for all, this should be means tested. However, others disagreed with means testing and felt that if someone had worked all their lives, they should have as much right to free care as others.

Some felt it would be fair that those who had lived in Jersey all their lives received free access to treatment – but that people who have not paid into the system should not enjoy the same benefits.

Payment for treatment

According to many respondents, significant numbers of people visit the Emergency Department rather than seeing a GP because there is a charge associated with the GP, whereas a visit to the Emergency Department is free. The majority agreed that if a charge applied to visit the Emergency Department for treatment of a minor condition, they would be more likely to go to see their GP. Many also suggested that GP consultation costs should be reviewed at the same time as Emergency Department costs.

Opinion was split about whether individuals would pay to wait a shorter time for a hospital appointment.

Efficiency

Many people felt that there are opportunities to improve the current system. Suggested ways to improve efficiency included reducing bureaucracy in health and social services, improving communication between organisations and bringing in more Third Sector and private sector organisations to provide care.

CONCLUSIONS

The vast majority of Islanders who responded agreed that health and social services should be redesigned to make them fit for the future and ready to deal with the challenges we will face. However, many were concerned about the actual implementation of these plans, the costs and associated risks.

4. WHITE PAPER A ten-year timescale

The White Paper outlines proposed changes to health and social care in the next 10 years. This timescale was selected (rather than the 30-year timescale in the Green Paper) because:

Services must change in the period to 2021 in order to cope with the increased demand in that period and simultaneously to prepare for the much larger increase in demand in the period from 2021 - 2030.

It is extremely difficult to make detailed plans for periods longer than 10 years

A new' hospital is required within 10 years

The States' planning cycle runs for 3 years; the Service Workstreams cover three Phases': 2013 – 15, 2016 – 18 and 2019 – 2021. This helps to ensure that financial and service plans can be consistently developed and co-ordinated to link in with States timescales.

Identifying the service areas

Following the Green Paper consultation eight service areas, and priority areas within these, were identified, based on:

Current / imminent capacity pressures

Green Paper feedback

Strategic importance

Whether the service change is a critical path' building block for future service changes

Eight crosscutting' enablers were also identified, these being the essential elements that support change.

Considering the previously agreed prioritisation criteria and understanding the current and future challenges for each area, priority schemes were identified in each Service Workstream:

Healthy Lifestyles - Alcohol

Services for Children – Early Intervention (0-5 years)

Hospital Services – Strategic Partnerships for Renal and Oncology

Adult Mental Health – Improving Access to Psychological Therapies

Older Adult Mental Health - Dementia

Intermediate Care

Long Term Conditions – Chronic Obstructive Pulmonary Disease (COPD), Chronic Heart Disease (CHD), Diabetes

End of Life Care

The Crosscutting Workstreams' are:

Workforce

Estates

Primary Care

Technology

Informatics

Commissioning

Funding

Legal and Regulatory

Producing plans

Lead officers, known as Senior Responsible Officers (SROs) within Health and Social Services were identified for each of these Service Workstreams' and Crosscutting Workstreams', and high level workstream plans were developed, through working groups and workshops with a range of stakeholders, for the next 10 years. Outline Business Cases were also produced for each priority area, for Phase 1 (2013 – 15).

Producing the White Paper

The Service Workstreams, Outline Business Cases and Crosscutting Workstreams were incorporated into the White Paper.

The White Paper developed the key themes from the Green Paper feedback:

Doing nothing is not an option'

A wide range of health and social care should continue to be provided on-island, with off-island care for specialist treatments where appropriate

Services should be free, or affordable, and available to all residents – regardless of the ability to pay

People should be able to live at home as long as possible

The role of nurses and other health and social care staff need to be enhanced

Integrated care is important, with professionals working closely together

Preventing ill health is as important as curing ill health

Mental health is as important as physical health

Jersey's Third Sector should be supported to take a larger role

Co-payments for GPs need to be considered

Services should continue to become more efficient, and bureaucracy should reduce

Rather than a questionnaire, Islanders were invited to state and outline their views.

5. THE WHITE PAPER CONSULTATION

The White Paper consultation took place between May and July 2012.

Building on lessons from the Green Paper consultation, engagement activities included public consultation sessions, individual meetings, focus groups, discussion forums and drop-in' sessions for staff, held in different locations and at different times of the day. In addition, mainstream media routes were used to raise awareness and inform Islanders e.g. JEP, Channel TV, BBC Radio Jersey, 103Fm, www.channelonline.tv, Parish magazines, the Public Consultation Register, Facebook and Twitter.

Over 1,000 Islanders were engaged in the White Paper through face-to-face discussions. More than 20 formal  responses  were  received  from  organisations,  the  majority  of  which  were  from  Third  Sector organisations. There were over 1,500 hits on the White Paper consultation page on the gov.je website, and over 130 responses were received from individuals, with a good age distribution:

Figure 4: Age profile of respondents to the White Paper

25%

20%

16-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ PNTS

15%

10%

5%

0%

Total

RESPONSES

Overall the vast majority of feedback received confirmed that Islanders remain positive and supportive of the proposed future direction for health and social services. Wider political / social policy issues regarding fairness and access to services for all Islanders, but in particular for the vulnerable members of society, were discussed in a number of forums. Key themes pertaining to health and social care included:

Primary Care

The majority of responses received across all consultation formats related to Primary Care, with the most common feedback relating to GP fees. Many of those that responded thought that fees were too high and can act as a deterrent to accessing care, particularly to those on low incomes or with children.

Improved access to Primary Care for under 5's was presented in the White Paper. This was frequently commented upon in the responses received, with strong support for this concept, either as subsidised or free GP appointments. Some people felt this should apply to all children under the age of 16 and those in full- time education, and some were of the view that these principles should also apply to the elderly and those with long term conditions.

Similar concerns were raised regarding access to dental care, which some felt was a specific element of Primary Care missing from the White Paper. Some respondents noted that dental services should be more accessible, through either free or subsidised care.

Many respondents were supportive of potential changes in delivery of Primary Care, with people stating that more nurses in GP practices was a good concept and should be explored further.

Some people suggested an expansion in the role of GPs, including GP clinics in the hospital and more out-of- hours access. It was suggested that this, along with changes to GP fees, would help to alleviate the pressure and the inappropriate use of the Emergency Department.

Staffing and Capacity

The majority of responses relating to staffing were focused on recruitment and retention, particularly of nursing staff. Islanders were concerned about the ability to recruit the large increase in nursing staff required to provide new services, with concerns about where skilled staff would be drawn from. People wanted to know what skills were needed, the existing gaps and what training opportunities were available for Jersey to both grow its own' nurses and up-skill the current workforce.

Respondents suggested that nurse pay should be reviewed and that affordable and appropriate accommodation should be available.

Alongside some of these reservations there were some very positive comments and recognition of the quality and hard work of staff currently working in health and social care, particularly at the hospital.

Funding

Respondents were anxious about the source of funding and whether enough money had been identified to deliver the White Paper. There were some mixed opinions about future funding sources, with numerous questions regarding tax and user-pays. Overall Islanders would like a fair mechanism that doesn't penalise people who have contributed to the system their whole lives, with some stating that tax relief should be available for those with private health insurance. Means testing was often discussed at meetings, and those people who offered a view on this mechanism felt that it would not be a fair or favourable way forward.

Conversely, a small number of responses took the opposite stance around paying for care and services. Some people felt that small charges for health and social care were acceptable in order to fund the required increase in services. Some responses suggested that a charge should be applied to those who misuse services, particularly the Emergency Department.

In relation to longer-term care, there was strong feeling expressed by many that individuals who have paid into the social security system during their lifetime should not have to sell their homes in order to pay for care, particularly in their old age.

Some of the feedback questioned how the money would flow around the system and which service areas and providers would receive the money. This was often raised during discussions with Third Sector organisations and GPs.

New Hospital

There was overall agreement within the consultation that investment is urgently required as current facilities are not fit-for-purpose. Opinion was divided as to whether, for the hospital, this should be a new build or a redevelopment of existing facilities. However, these comments were often linked to concerns about funding.

Carers

Support and recognition for carers was a recurring theme, with very strong views expressed throughout the consultation. Respondents felt that more recognition needs to be given to the important role of carers, and that a wider and increased amount of support, advice and training should be made available. Interestingly, these conversations often highlighted a lack of awareness of the current services and support mechanisms that are already available.

There was recognition that failure to support carers could result in carers becoming patients themselves. Islanders expressed strong views that more respite services are urgently required.

Other responses suggested the need for more support both financially and in terms of providing advice, training and recognition for carers. The important role of young carers was also noted, along with the need for continued cross-departmental working to support individuals.

Third Sector

The Third Sector is frequently referred to throughout the White Paper as a potential provider of services in the new vision for health and social care. The importance of the sector as both a partner and provider was recognised from an early stage in the development of the proposed new approach.

The majority, though not all, of the feedback received about Third Sector issues and the White Paper came from the Third Sector itself.

Overall, Third Sector groups are supportive of the proposals with some slight nervousness regarding the impact on their organisations. Many organisations were in agreement with the concept of working with the States in partnership to deliver services, and many expressed the need for this relationship to be as equals and in a collaborative and integrated model. It was noted that this would require a culture change and development of additional capacity and capability.

Care in the community

Respondents were strongly in favour of providing more care in individuals' homes, to enable people to maintain their independence for as long as possible. The concept of choice was overwhelmingly supported, along with appropriate mechanisms to limit social isolation and the need to ensure that care in the community allows people to live, not just exist'.

In particular, the concept of an Active Ageing and Wellbeing Centre was strongly supported by those who responded, and many Third Sector organisations expressed an interest in being involved in this.

A few respondents expressed the view that that community care won't be appropriate for everyone, and regulation and monitoring the quality of care was identified as a concern, with some people noting the need to carefully select service providers, especially those involved in care in an individuals' home. In addition, comments on the move to care in the community were often linked with concerns about funding and staffing capacity.

Mental Health

Islanders who participated in the consultation were generally very positive about the outline plans for Improving Access to Psychological Therapies (IAPT) and the inclusion of mental health in the White Paper. Some people noted the need to remove the stigma associated with mental health issues and supported service delivery in a multi-purpose setting. Others commented on the need to change perceptions of mental health and that a more positive approach around mental health and wellbeing should be promoted.

In public meetings, a view was expressed that traditionally mental health services have been perceived as a "Cinderella Service" and that this needs to change. Some mental health services also need to be prioritised, in particular for individuals in crisis. It was hoped that the changes proposed in the White Paper would act as a catalyst for this.

Equality and access

Issues of social equality and fairness were often mentioned in relation to the key themes, in particular around access  to  Primary  Care  and  funding.  These  issues were  most  acutely  expressed  by  those  groups  who currently find access to services more difficult due to hearing and visual impairment. These groups urged Health and Social Services (and the States) to be mindful of their needs in the design of new services and facilities.

Adult Special Needs Services

A small number of responses from staff currently working in adult Special Needs services expressed disappointment and concerns about the lack of prominence of, and funding for, these services in the White Paper. Respondents commented on poor state of current facilities and accommodation as well as the lack of resources.

Services for Children

Third Sector organisations involved in the delivery of services for children strongly supported the prioritisation of Early Intervention, with strong views expressed regarding the range of alternative service models for meeting the needs of this client group.

CONCLUSIONS

The White Paper outlined a vision of health and social care in Jersey in the next 10 years. It presented outline plans for achieving the vision, but did not present detailed plans for the full ten years of implementation. This Report gives clear information about likely changes in the first three year Phase, and work is now underway to develop Phases 2 and 3.

Over 1,000 Islanders were engaged with as part of the eight-week consultation, and engagement with a range of Third Sector organisations was prioritised. Feedback on the White Paper was overwhelmingly positive, and identified a need to prioritise and/or consider further:

Payment mechanisms for Primary Care

Workforce, particularly nursing

Funding for health and social care following Phase 1 (2013 – 2015)

Support to carers

The role, relationship and continued involvement of the Third Sector - including capability development

The Active Ageing and Wellbeing Centre

Existing services for acute / crisis mental health

Access, especially for those with special needs, physical and sensory impairment

The detailed models of care for services for children

4. THEPROPOSEDNEW WAYFORWARD FORHEALTHANDSOCIALCARE

The proposed new way forward for health and social care identifies the strategic investments that are required in order to continue to deliver safe, sustainable, affordable services now and into the future.

It should be noted that this does not replace the ongoing service developments that are already planned and that have already commenced, nor is it intended to replace the need for services to be continually monitored

and reviewed, and operational changes made as required in the future.

One example of this would be the Special Needs Service, where significant changes are already being developed, and services increased to meet identified needs – particularly in relation to estates.

As  each  of the  outline  plans  are  developed  into  detailed  plans,  access  and equalities  impact  must  be considered, in order to endeavour to incorporate the particular needs of individuals with physical disability and/or sensory impairment.

1. STRATEGIC VISION PRINCIPLES

The vision of services which are safe, sustainable and affordable was distilled into a set of strategic design principles in late 2010. These were developed by stakeholders across health and social care, and ratified by the Ministerial Oversight Group:

Safe

- Clinical/service viability – overcoming the challenges of low patient volumes, delivering high quality care and minimising risk

- Sustaining a culture of clinical governance, safety, learning and transparency

Sustainable

- Services that are efficient, effective and evidence-based

- Optimising estate utilisation and ensuring the estate is fit-for-purpose

- Supporting and utilising the workforce to the best of their abilities

- Engaging the public in self-care and with consistent access and thresholds

- Using robust data to support decision making based on fact, and including patients and the public in service design

Affordable

- Ensuring financial viability and reducing the impact of diseconomies of scale, with value for money, an understanding of the costs of care in Jersey and robust procurement

- Establishing funding streams and developing funding models that incentivise care and cooperation

2. THE NEW WAY FORWARD  – WORKING ACROSS SERVICE PROVIDERS AND INTEGRATING CARE

The proposed model of health and social care services will support and enhance the elements of the current system that are positive and will, over the next 10 years, transform the system so that it continues to meet the needs of Islanders.

Care will be integrated as seamlessly as possible, with the individual patient or service user at the centre. Teams of social care, home care, medical, nursing, occupational therapy, psychology and other staff will work together with the Third Sector and private sector providers to achieve this.

Frontline service integration will be supported by a professional mindset that seeks the individual's views, choices and decisions about their care package, and ensures that needs drive services and not the reverse.

Organisationally, teams will be integrated and clear partnership arrangements will be developed across service providers. Multidisciplinary teams will be introduced, with integrated care pathways that clearly define roles and responsibilities – including with hospital, Primary Care and Third Sector / Parish services.

Systems to improve  communication will be introduced, through improving and sharing information systems. This will include multidisciplinary notes that can be shared by all professionals involved in an individual's care. Single assessment and care planning will ensure the individual's holistic needs are identified, and care navigators will ensure co-ordination and access to the right range of services.

Where appropriate, service provision should move away from residential care and institutionalisation towards an increase in community provision to allow service users to integrate and lead independent and productive lives as much as possible. This will relieve pressure on hospital beds, and will help the hospital to manage within its current facility until the new' hospital is available. It will also support more children to be cared for in family settings.

The drive to improve efficiency, effectiveness and productivity will continue. The Jersey Lean System (a service redesign approach) will have been introduced into health and social care by early 2013, with a number of staff in a range of settings / services trained to identify and deliver service improvements utilising the Lean' service improvement methodology.

Awareness and information will increase, and will be streamlined with improved accessibility. Consideration will be made particularly of the needs of sensory impairment. Individuals who are at risk of developing certain conditions will be identified through increased screening, case finding and risk stratification. This will support proactive care to delay the onset or progression of long term conditions.

Proven, cost effective  technology will enhance services where appropriate, for example telehealth and telecare to enable individuals to be cared for in their own homes, and telemedicine to support clinicians working with off-Island colleagues.

The new system will be underpinned by robust Commissioning. This will ensure that the health and social care needs of Islanders are understood and services are available to meet these needs. It will also ensure visibility over quality and outcomes and improved value for money. Commissioning will also support a range of providers, including those in the Third Sector and private sector, to deliver services.

The vision outlined above is ambitious; this will be a programme of change that is unprecedented in Jersey, and will lead to a health and social care system that will be a model of best practice for isolated, rural and island communities.

In order to achieve this, changes must be introduced in the right order and at the right pace. The majority of changes which have been prioritised for Phase 1 relate to Community services. As these begin to have impact, the strategy for services within hospital and Primary Care settings will be developed. These will then be implemented during Phase 2 (2016 – 18).

5. SERVICE WORKSTREAMS

This section presents each of the Service Workstreams in turn, and outlines the proposals for developing services, within the strategic vision for health and social care. Further detail for Phase 1 (2013 – 15) is available within the Outline Business Cases (OBCs). The feedback from the Green Paper and White Paper consultation has been used to develop our thinking regarding prioritisation and service models:

1. HEALTHY LIFESTYLES (STARTING WITH ALCOHOL PATHWAY)THE VISION FOR HEALTHY LIFESTYLES

To promote healthier lifestyles and behaviours, delay the onset or progression of poor health and social care, and improve an individual's health, wellbeing, independence and quality of life. This will contribute towards a community that values, protects and takes responsibility for its own health and wellbeing, and as a result depends less on institutionalised health and social care.

WHY THIS HAS BEEN PRIORITISED

Over 85% of adults in Jersey rate their health as good or better, however, Jersey faces some significant public health challenges, in particular regarding alcohol and smoking. We need to improve health and wellbeing and reduce pressure on health and social care services. However, at present there is:

Insufficient awareness of how lifestyle choices impact on health and wellbeing

No integrated prevention strategy

Very limited coordinated promotion of self-help

No comprehensive picture of population health needs

Limited coordination and integration between different services working with people who may have a similar underlying issue

OUTCOMES TO BE ACHIEVED

Reduction in unwanted variation in health and social care outcomes

Increased early identification of disease

Improved health and wellbeing, including improvements in access and equality

Demonstrable behaviour change, with more Islanders adopting healthy behaviours around tobacco, alcohol, exercise and diet

Increased early diagnosis of cancer

Increased public awareness and empowerment for informed choices about risk factors such as tobacco, alcohol, exercise and diet

Increased awareness across key stakeholders e.g. teachers, police

Increased numbers of individuals identified as at risk' as a result of screening - with brief and extended interventions provided

Reduced pressure on hospital

Greater integration of services, particularly with Primary Care and Third Sector

Leadership and operational guidance from professional champions

FEEDBACK FROM CONSULTATION

The Green Paper consultation reported that 90% of respondents believed that prevention is as important as cure; some felt that this was an area where the States of Jersey need to focus their attention for long term gain.

73% agreed that individuals have a responsibility to care for themselves, once provided with the tools and skills to do so. Some respondents noted that keeping fit and healthy is the responsibility of the individual and should be encouraged as widely as possible. Others feel that everyone should have equal access to medical support, regardless of whether they look after themselves.

Feedback from the White Paper consultation supported the prioritisation of alcohol as the key priority. Islanders openly recognised the impact that alcohol dependency has on the hospital, especially the Emergency Department. They also recognised the interdependence with wider social policy, including housing, education, criminal justice and the potential impact on risks, particularly for young women.

Feedback from the White Paper also highlighted the importance of encouraging healthy lifestyles for children and young people, particularly around the importance of play and leisure time involving physical activity.

The need to streamline and simplify the multiplicity of information sources, whilst continuing to support Third Sector organisations, was identified.

SERVICE DEVELOPMENTS

The focus of this workstream is to design prevention programmes that successfully address the key determinants of poor health and wellbeing.

A rolling programme of  Jersey Strategic Needs Assessments (JSNA) will be undertaken across States Departments, led by the Heath Intelligence Team in the Public Health department. This will help to develop an understanding of how the determinants of health, including lifestyle risk factors, contribute to morbidity. It will also provide a clear picture of the current health status of Islanders, and identify and project their health and social care needs for the coming three to five years. The JSNA will:

Incorporate the wider determinants of health (e.g. housing, employment, education) to provide a comprehensive view of the population's health and social care needs. It is well known that poor housing and education can have a detrimental effect on health; it is important that these underpinning foundations for health are identified and addressed as part of wider social policy at the same time as lifestyle issues

Develop population profiles for the key risk factors (including diet, exercise, tobacco and alcohol consumption) to the main chronic disease conditions which contribute to levels of morbidity (obesity, cardiovascular and respiratory disease, and diabetes). These profiles will form the basis for commissioning population-based preventative services such as smoking cessation, as well as informing social marketing campaigns

Consider the specific communities whose health may be worse than others, and identify equality and access issues, for example relating to sensory impairment, physical disability and/or special needs

Develop pathways for conditions that are associated with individual behaviours and lifestyle, for example alcohol and sexual health. The pathway approach will improve the integration of services and encourage an increased role for Community and Primary Care services, which will in turn reduce the pressure on hospital services and improve outcomes.

2013 - 2015

The lead OBC is focussed on the alcohol pathway. The revised alcohol pathway will be based on NICE guidance1011  and other key documents. It will support a consistent approach to addressing alcohol misuse, through a pathway developed in consultation with clinicians, the Third Sector and service users. The aim is to:

Improve the identification and treatment of alcohol misuse

Increase access to alcohol services toward 20% in three years

Encourage more people to proactively seek information to help themselves and others to drink sensibly

Improve the timely use of health services to reduce harmful patterns of alcohol consumption

Increase the number of people being supported sooner to reduce their alcohol consumption before any crisis or long lasting damage

Increase the number of severely dependent drinkers taking up non-hospital detoxification and relapse prevention programmes.

The future Alcohol Strategy and revision of the Alcohol Licensing Law will underpin these service changes. The pathway comprises:

Self  Care  /  Guidance  -  Media  campaigns  and  targeted  social  marketing,  with  evidence-based programmes targeting those at risk to complement the existing generic information currently provided as part of the local PSHE Curriculum in schools

Screening and Case Finding - Validated tools to screen for alcohol misuse, delivered in Primary Care (GPs and Pharmacists) to provide early detection of alcohol related problems. This will be supported by a regular review of practice populations to identify high risk individuals. Key gateways into the hospital (Emergency Department, Day Surgery, Outpatients, Emergency Admissions Unit and Gastroenterology) will screen opportunistically in key target audiences. A care bundle approach will be used to ensure patients are not repeatedly assessed but are offered appropriate interventions

Brief and Extended Interventions - once screening has been completed practitioners will offer brief advice and / or will refer to specialist services. Rapid response to referrals post-screening will be achieved through increasing the capacity of the Hospital Alcohol Liaison Service and ensuring expertise is built into future mental health services

Non-hospital Detoxification / Relapse Prevention - Increasing the amount of screening will lead to an increase  in  the  number  of  alcohol  dependent  patients  identified  for  non-hospital  detoxification.  A

10 Guidelines on Diagnosis, Assessment and Management of Harmful Drinking and Alcohol Dependence Volume 1 -3: NICE

11 Public Health Guidance 24: (2010): Alcohol-Use Disorders; Preventing the Development of Hazardous and Harmful Drinking: NICE

consistent referral route will be implemented, which will enable capacity to be better utilised and will increase the amount of detoxification completed in the community. On completion of a detoxification, relapse prevention programmes will help support the client and family to adapt and to maintain abstinence, thereby reducing the risk of readmissions and alcohol-related morbidity

2016 - 2018

The focus will be on developing a comprehensive and co-ordinated approach to screening, continuing to collate information to assess health and social care needs, and increasing awareness and services for diet, exercise, tobacco and sexual health.

The approach and methodology for population screening will be developed from 2016 onwards. This will be a coherent and coordinated approach, initially focusing on key risk factors for chronic conditions such as tobacco, alcohol, obesity. The results of screening will enable prevention programmes (prescriptions for health') to  be  focused  on  key  groups  according  to  the  known  profiles.  In  addition,  age-related  health screening at 50 – 55 years old for common conditions such as type 2 diabetes and high blood pressure will be developed, as similar programmes have been shown to have a positive impact in reducing the level of disability caused by these conditions later in life.

Prescriptions for health' will allow clinicians to prescribe' health promoting interventions, such as exercise, weight management and smoking cessation in addition to traditional prescriptions e.g. for antibiotics and other medicines. There is good evidence to support this type of approach from the National Institute of Clinical Excellence.

Developing  pathways for prevention, diagnosis, treatment and recovery for conditions associated with individual behaviours and lifestyles such as sexual health and illegal drugs will ensure patients access the correct services at appropriate times. The Alcohol Pathway will serve as a proof of concept' in terms of resource requirements for risk profiling, awareness, screening and care pathway co-ordination across sectors and agencies. Future pathways will incorporate:

Social marketing and public awareness

Improved access to information

Developing the role and capacity of Primary Care

Expert leadership across the pathway

Clear commissioning priorities to inform third / private sector involvement

Robust indicators based on JSNA and population risk profiles.

A coordinated cancer strategy will ensure prevention and earlier interventions give greater opportunity for care to be delivered in the community with the support of telehealth and telecare. The cancer strategy would encompass the complete care pathway including:

Primary prevention, ensuring cancer prevention messages are included in the messages around smoking, alcohol, diet and exercise

Population screening, focusing on improving uptake and monitoring new developments in current and emerging screening programmes

Early intervention and treatment, proving quick and timely advice, guidance and treatment

Recovery, providing appropriate community-based support to individuals and family members.

In practice, investment in promoting cancer awareness and improving early diagnosis may not reduce the number of cancer patients but will significantly reduce the costly treatment of advanced cancer, commonly undertaken off-Island.

2019 - 2021

The model for healthy lifestyles will continue to be expanded in Phase 3, including:

Mental Health – Focusing on community-based programmes that support and promote mental health and reduce stigma associated with mental illness. A number of national programmes have been implemented which have had a positive impact on reducing the stigma associated with mental illness, and best practice will be incorporated from these programmes

Illegal Drugs – A repeat of the Imperial College survey which described drug-taking activity in the Island, with services reviewed and developed as a result

Healthy Ageing – Focusing on key factors which reduce independence, including:

– A comprehensive falls prevention programme

– Reducing morbidity due to seasonal flu

– Maintaining health and independence by increasing the uptake of health promoting initiatives which provide social as well as physical benefit

2. REFOCUSING SERVICES FOR CHILDREN (STARTING WITH EARLY INTERVENTION) THE VISION FOR SERVICES FOR CHILDREN

To improve outcomes for children measured in terms of their health, social wellbeing and educational attainment. This applies to all services provided to children and will be achieved by close working between States Departments and the independent and Third Sectors.

A fully integrated service delivery model will be implemented with services "wrapped around" the child and family, with respite care, a professional fostering service and a range of choices for services from a network of providers.

Service developments commence with early intervention, focusing on pre-birth to aged five. The principles and lesson learned will be incorporated into planning for each of the age groups as appropriate. In 2016-2018 the focus will be on children aged 5 – 11 years, whilst in 2018-2021 the focus will be on children aged between 12 and 18 years.

WHY THIS HAS BEEN PRIORITISED

Children and their families receive health and social care from a wide range of departments and agencies. This diversity is essential, but integration and co-ordination is required.

Referral rates into Services for Children are higher than in English authorities, and Jersey has a large number of children placed in residential care as opposed to foster care. It is acknowledged that we have less fostering and adoption than we would like, for example because we have a very high number of families where both parents work.

Over the past decade evidence has emerged that the quality of experiences in the first five years of life can have a profound impact on a child's future development, learning, behaviour, health and the ability to build positive, secure attachments, and on truancy, conduct disorder and risk-taking behaviours such as substance misuse and mental illness. Potential economic implications include an estimated cost for each child with untreated behavioural problems of £70,000 a year by the time they reach 28 years old – 10 times the cost of children without behavioural problems, an average estimated cost of £430,000 for an individual spending a lifetime on benefits.

Early Intervention' improves a child's social and emotional capability to help break intergenerational cycle of disadvantage and underachievement. Health economists have calculated that a return of up to three to seven times the original investment could be achievable by the time the young person is 21 years.

OUTCOMES TO BE ACHIEVED

Outcomes for children will be improved, with a reduction in the need for (higher cost) reactive services later in both childhood and adulthood and:

Reduced number of children requiring off-island residential placements

Reduced volume of mental health referrals

Reduced need for residential care

Holistic, health and wellbeing needs met, through a Common Assessment Framework that is appropriate to Jersey

Improved integration of services and joint working / staff morale

Improved health outcomes of Looked After Children

Diversified provision by working collaboratively with Third Sector and private providers

Reduced obstetric complications as a result of pre-birth support given to vulnerable families

Improved maternal / child relationship

Reduced postnatal mental health issues

Improved joint working in relation to child protection and safeguarding

Reduced inappropriate Emergency Department activity

Longer term reductions in antisocial behaviour and crime

Integrated policy development

FEEDBACK FROM CONSULTATION

The Green Paper consultation reported that 81% of respondents agreed with increased investment in children and young people.

The White Paper consultation engaged specifically with a number of Third Sector organisations involved with children and families. The prioritisation of the 0-5 age group was supported, and respondents favoured improving access to Primary Care through a fixed number of free or subsidised GP visits. It was also suggested that a Head of Early Years for Health and Social Services should be appointed, to work closely with the Head of Early Years at Education, Sports & Culture to ensure an integrated strategic approach.

The principles underpinning the proposed changes to services for children were supported. However, the exact service model contained within the White Paper was challenged. This will continue to be discussed and developed, based on evidence and best practice applied to Jersey, and in accordance with our health and social care needs. These discussions will continue as the detailed plans for service delivery from 2013 are developed, and will be held with a range of stakeholders and experts in the field.

SERVICE DEVELOPMENTS

Services for Children will be developed in three phases, relating to the age of the child:

2013 – 2015 - EARLY  INTERVENTION FOR  CHILDREN  (FROM PREGNANCY TO THE AGE OF FIVE

YEARS)

Additional support and financial payment for  professional fostering, to support children with challenging behaviours

Significantly enhanced Children's respite services; buildings will be modernised, and additional staffing capacity secured in order to provide more flexible respite which can be adapted to fit different families' needs. The overall aim is to enable children and their families to gain early access to the right support and enable those families to stay together for longer

Increased awareness and self help. Easily accessible self-help materials to assist individuals in developing their skills and knowledge about parenting. There will be particular focus on the antenatal period with specific programmes delivered in conjunction with existing midwifery services. In addition there will be improved signposting towards existing local community groups to assist parents in sharing and supporting each other in caring for and supporting a healthy, thriving child

Improved access to Primary Care for children under five years' olds whose parents require rapid access to health advice or assessment when hospital is not appropriate

Increased Community Midwifery, to offer choice of service and location for ante-natal care

Care co-ordination. National guidance for working effectively with families with children who have complex needs stress the importance of a key worker system. The key worker would work in partnership with the family to co-ordinate service provision and provide ongoing support

Early intervention. Increasing evidence indicates the need to identify and intervene early in order to achieve the best health and wellbeing outcomes for families who have additional needs. Focused on those families assessed as having additional needs during the antenatal period, a two-year programme will provide integrated support across care settings and across organisations. A multi-agency network would be formed around the family, and the family would be encouraged to access a range of support services, drawing on both existing and new services provided by a range of organisations including the Third Sector. This approach will provide both parent and child the best chance of developing resilient, positive relationships which enable the child to thrive during the early years of life and lay the foundations for a healthy life.

2016 – 2018

Following the focus on early intervention (for children from pre-birth to age five), in the period from 2013 to 2015, the focus in 2016 – 2018 will be on children aged 5-11. Children and their families can expect to receive care from a network of practitioners, with appropriate services wrapped around the child', based on an assessment of all the child's needs. This will include:

Mapping and reviewing existing universal and tiered service provision, with a view to identifying unmet need, service duplication and overlap and areas which require improvement and scope for innovation. The development of a sustainable model for service provision will be prioritised, including the extent to which existing Multi Agency Service Teams – already established in secondary schools - can support similar functions in primary schools

Improving Access to Psychological Therapies (IAPT) for children, based on learning from the first IAPT for children pilot sites in the UK. This will result in a more comprehensive range of services for children and adolescents with mental health issues. Evidence-based therapeutic interventions such as cognitive behavioural therapy, systemic family therapy, interpersonal therapy and parenting strategies will be delivered for a range of difficulties such as anxiety, low mood, parenting difficulties and conduct problems

Continuing to invest in respite services and professional fostering

Developing a child health profile based on existing and future surveys and other data sources such as the child health database

2019 – 2021

Key strategic service developments will include:

Mapping and reviewing services for young people aged 11 – 19, using similar approaches to those introduced for other age groups

Aligning services for children via multi agency care pathways

Reviewing and enhancing the Children's and Young People's Plan, including the possibility of pooled budgets and joint commissioning arrangements between States of Jersey Departments.

3. ADULT  MENTAL  HEALTH  SERVICES  (STARTING WITH  IMPROVING  ACCESS TO PSYCHOLOGICAL THERAPIES (IAPT)

THE VISION FOR MENTAL HEALTH SERVICES

To deliver person-centred services in safe, flexible and appropriate environments, with a range of providers supported and standardised, high quality delivery of services in a single care pathway by 2021.